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Health Commissioner finds DHB in breach of Health Code over care failures

Contributor:
Fuseworks Media
Fuseworks Media

Health and Disability Commissioner Anthony Hill today released a report finding South Canterbury District Health Board (DHB) and Pacific Radiology in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failings in the care provided to a woman in her 60s.

In 2010 the woman was referred by her general practitioner (GP) to the Emergency Department (ED) to investigate a possible pulmonary embolism (PE). The woman was assessed and her discharge summary recommended follow-up with a chest X-ray in six weeks’ time.

The six-week follow-up did not occur. This led to a missed opportunity for additional investigations, and a probable delayed diagnosis of cancer. Anthony Hill was critical that there was a breakdown in communication from the DHB to both the woman and her GP.

Five and a half years later, in 2016, the woman presented to her GP who referred her to the DHB for a semi-urgent ultrasound (US) scan in relation to classic gall-bladder symptoms. The accepted timeframe for a semi-urgent US scan was two to four weeks.

The referral was waitlisted and a month later outsourced by the DHB to the private radiology service. It was two months before the radiology service sent an appointment letter to the woman, with an appointment date in another two months time. This was a total waiting time of almost five months for a semi-urgent scan.

Anthony Hill was critical that the contract between the DHB and the radiology service did not include detail on the outsourced services, that the DHB did not have systems in place to manage and monitor the outsourcing of scans and that there was a lack of communication from both the DHB and the radiology service about the referral.

Anthony Hill recommended that the DHB provide an update on the recommendations in their own review of this case, provide an update on the outsourcing agreement with the radiology service, undertake an audit and apologise to the woman’s family.

Anthony Hill recommended that the radiology service provide an update on the outsourcing agreement with the DHB, review its policies, undertake an audit and apologise to the woman’s family.

The full report for case 17HDC00163 is available on the HDC website.

https://www.hdc.org.nz/decisions/search-decisions/2019/17hdc00163/

4 November 2019

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