[ad_1]
123rf
The reporting radiologist’s registrar recommended that the man undergo a “respiratory opinion” and documented a discussion with the emergency department registrar.
A man died after cancer spread from his lung to his brain, even though doctors had detected a lung injury four months earlier.
The Canterbury District Board of Health “denied the man the opportunity for early diagnosis and intervention for his lung cancer,” says a report from the Health and Disability Commissioner (HDC).
Do you know more? Email [email protected]
The man, in his 50s, was taken by ambulance to the emergency department (ED) of a public hospital on March 18, 2017, after an accident.
A CT scan revealed that he had multiple spinal compression fractures and a right upper lung injury.
READ MORE:
* Doctors in the Christchurch cancer department, which are understaffed, are trained in stress management
* Waikato DHB care was found to be deficient after the man’s death.
* Shorter socks, paper cups, and cheaper medications: Canterbury health authorities describe cost cuts
The reporting radiologist’s registrar recommended that the man undergo a “respiratory opinion” and documented a discussion with the ED’s registrar.
The man spent seven days in hospital receiving treatment for his spinal injuries, but health professionals did not speak of the lung injury.
The man’s family was informed of the injury, but it was not documented in his emergency medical record or discharge summary, and no documentation of the problem was provided to him or his family.
His GP received a copy of the ED’s medical record and discharge summary, but was not notified of the lung injury.
123RF
A report by the Commissioner of Health and Disability found that the man was denied “the opportunity for early diagnosis and intervention for his lung cancer.”
Almost five months later, on August 2, the man returned to the hospital because he had difficulty speaking, a drooping right face, and weakness in his right arm.
CT scans revealed that a primary lesion in the upper lobe of the right lung had spread to the brain.
The man was diagnosed with metastasized lung cancer and died shortly after.
The HDC found that the CDHB had violated the Consumer Rights Code for Health and Disabled Services, as no doctor took responsibility for the incidental finding of the man and it was not recorded in his discharge summary or communicated to his GP .
“This denied the man the opportunity for early diagnosis and intervention for his lung cancer,” the report says.
JOHN KIRK-ANDERSON / FAIRFAX NZ / Stuff
Sue Nightingale, medical director for the Canterbury District Board of Health, says the care given to the man was poor.
HDC recommended that the board of health provide you with a copy of its new mandatory departmental policy on incidental findings and create educational material on standards of practice.
CDHB Medical Director Dr. Sue Nightingale said she had personally apologized to the man’s family for “the poor level of care provided” and expressed her condolences.
“Canterbury DHB accepts the findings of the Commissioner of Health and Disability. We also recognize that our standard of care was poor in this case, ”he said.
“We would like to assure the public that we have made improvements to our systems and processes to reduce the chances of an incident like this happening again.”
The board was following HDC’s recommendations to reinforce the processes required for such findings and the follow-up actions that staff should take, he said.
