Woman waits nine months after tumour diagnosis

Anthony Hill. Photo: HDC
Anthony Hill. Photo: HDC
The Health and Disability Commissioner has ordered the Southern District Health Board to provide him with its most recent audit of its new electronic medical records system.

The demand comes after a failure in its old system meant no follow-up action was taken for nine months after a woman was diagnosed with a tumour.

The 45-year-old woman had an MRI performed in May 2015 after sustaining hearing loss in her right ear.

The scan detected a tumour, but the results were still languishing unanswered in the electronic system nine months later, a decision by commissioner Anthony Hill released yesterday said.

‘‘At the time of these events at SDHB, there was both an electronic and a paper-based results system.

‘‘While the result was available to be seen in the electronic system, until September 2015, there was no requirement that clinicians at SDHB acknowledged test results in the electronic system.’’

The woman’s doctor routinely used a paper-based records system, which ran alongside the electronic version.

Access logs showed the doctor viewed the report on May 14, but the commissioner accepted the doctor’s word he did not recall this and had not read it.

The doctor did not receive a paper copy of the woman’s result, so did not follow up.

‘‘There were multiple opportunities . . . when the result could have been ‘lost’ and therefore not brought to Dr B’s attention,’’ the commissioner said.

The commissioner said there were numerous mitigating factors, but criticised the doctor waiting until a scheduled appointment with the woman to tell her about the tumour, rather than contacting her immediately.

The tumour, which was benign, was subsequently removed.

The commissioner said the woman was now permanently deaf in her right ear, her balance was affected, and she experienced headaches.

‘‘She is concerned that this is as a result of the delayed surgery.’’

The SDHB told the commissioner its expert doctor’s opinion was that for surgery such as the woman needed, removing the auditory nerve was the best guarantee for total removal of the tumour.

It also said since the events in the case, policies for electronic acknowledgement of results had been introduced.

The commissioner acknowledged that, but said at the time of the woman’s treatment ‘‘the lack of a clear, effective, and formalised system within SDHB for the reporting and following up of test results meant that this result was not appropriately acknowledged, actioned, and communicated’’.

The commissioner asked for the SDHB’s most recent audit of its electronic medical record system.

He also recommended both the doctor and the SDHB apologise to the woman.

SDHB chief medical officer Nigel Millar said the organisation accepted the commissioner’s opinion without qualification.

‘‘Southern District Health Board has provided a sincere and unreserved apology for the unreasonable delay in identifying the abnormal report, and we acknowledge the distress it caused to the person affected,’’ Dr Millar said.

‘‘Since the events in 2015-16 we have changed our IT system and it provides a view of all outstanding reports to each clinician.

‘‘We continue to monitor the system.’’


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