Hospital Negligence Leads to Missed Lung Cancer Diagnosis: Patient Angered by Lack of Communication
A man’s lung cancer diagnosis was tragically missed due to hospital negligence, leading to his eventual death. The patient, known as Mr. A, expressed his anger and disappointment at the healthcare staff who made critical decisions about his care without consulting him. An investigation by the Health and Disability Commissioner (HDC) found both the doctor and the hospital, Te Whatu Ora Waitaha Canterbury, in breach of the Code of Health and Disability Services Consumers’ Rights.
In early to mid-2019, Mr. A, who was in his 80s and had several pre-existing conditions including diabetes, heart disease, high blood pressure, and elevated cholesterol, visited a public hospital emergency department multiple times due to chest pain. On two separate occasions in August, he was admitted for chest pain, and although chest X-rays were taken, no abnormalities were noted. However, a subsequent review of the August 6 X-ray revealed a 15-millimeter density indicative of a mass.
On August 29, Mr. A returned to the emergency department with pain and weakness and underwent another chest X-ray. The radiology report the following day noted a 19mm nodule and recommended a CT scan for further investigation. Unfortunately, before the report was available, Mr. A was discharged. When a general medicine physician, Dr. B, finally accepted the report on September 2, he failed to take further action due to confusion caused by another patient with a similar name. Dr. B mistakenly believed both reports belonged to the other patient and marked Mr. A’s report as accepted. Consequently, neither Mr. A nor his GP were informed of the X-ray results as his discharge summary was not updated.
It wasn’t until October 6 that Mr. A returned to the hospital, unable to move and in pain, and underwent another chest X-ray. The radiology report from the same day revealed a 35mm mass-like density that had significantly increased in size compared to previous X-rays. The report also questioned whether the recommended CT scan had been conducted. Shockingly, Mr. A was only informed of the mass more than four weeks after it was initially discovered. He expressed deep distress upon learning he had lung cancer and criticized the medical staff for their lack of respect in making decisions about his treatment without consulting him. He also feared that others might suffer a similar fate due to such negligent practices.
However, the issues with Mr. A’s care did not end there. Even after the referral for a fine needle aspiration biopsy was issued on October 7, it was delayed until November 5 due to strike action by medical imaging technicians, which affected outpatient appointment scheduling. Ultimately, Mr. A was offered radiation or palliative care and opted for radiation. However, he passed away in 2020.
Although a medical oncologist stated that the delay in diagnosis likely did not significantly affect the outcome for Mr. A since his cancer was rapidly growing and likely at an advanced stage, Deputy Commissioner Deborah James found the failure of Dr. B to act upon the radiologist’s report on August 30, as well as the delay in informing Mr. A about this failure, to be a departure from the standard of care required. James emphasized that this failure had serious consequences as it led to the CT scan not being conducted in a timely manner and deprived Mr. A and his GP of the opportunity to take appropriate action.
Furthermore, James noted a similar case reported earlier this year by the HDC, where a senior emergency medicine clinician also breached the Code by failing to take action on a radiologist’s report of a lung mass. In Mr. A’s case, she highlighted that despite several clinicians being aware of the failure to act on the report, none took responsibility for promptly informing Mr. A of the error.
The HDC found Te Whatu Ora Canterbury in breach of the consumer’s right to be fully informed and recommended that the physician who handled Mr. A’s case undergo an audit of 50 radiology reports to identify whether significant abnormal findings were being properly addressed. Recommendations were also made to Te Whatu Ora, including a formal apology to the family.
This case underscores the importance of effective communication, timely action on medical reports, and ensuring that patients are fully informed about their conditions. It serves as a harrowing reminder of the significant impact that hospital negligence can have on patients and their families.
