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A ``dangerous flaw'' in a computer system meant a woman's X-ray result was forgotten and her cancer was not picked up until it was terminal.
In a report released yesterday, Health and Disability Commissioner Anthony Hill found against the Southern District Health Board, but cleared the doctor who forgot to follow up the result.
When it looked into the problem, the board found a ``significant number'' of other radiology results had been forgotten, and of those, 23 needed some kind of follow-up.
In 2013, the woman (66) was seen by a Southland Hospital emergency department doctor who diagnosed chronic obstructive pulmonary disease with acute asthma, and discharged her.
A radiologist later performed the routine formal X-ray read, picking up a 15mm by 10mm mass that needed further investigation.
The doctor got the result, but as she was going on annual leave, she decided to action it when she returned.
She did not know the report would slip out of the visible part of the computer system.
When the patient returned to the emergency department nearly two years later, in 2015, she was diagnosed with lung cancer, which had spread to her brain. She died shortly afterwards.
Neither the patient nor her GP were told about the 2013 result until 2015.
The SDHB found a ``significant number'' (the report did not say how many) of other results had been lost, 23 of which required following up.
``The remainder did not require any further action other than a more in-depth review or a telephone call to the patient.''
Mr Hill said the DHB failed to provide the patient with an adequate standard of care.
The doctor, referred to as Dr C in the report, was working in an ``inadequate system'', and while she could have done more to ensure the report was followed up, she did not know about the IT flaw, Mr Hill said.
William Jaffurs, a North Island doctor who reviewed the case, called the IT issue ``dangerous''.
``The reviews from SDHB clearly identify a dangerous flaw in the management of verifying and acknowledging reports which allows the reports to become virtually invisible after first viewing but prior to acknowledgment,'' Dr Jaffurs told the Health and Disability Commissioner.
The DHB told the commissioner there had been a lack of understanding among ED doctors about how the system worked.
Dr C told the commissioner she regretted what happened.
``I regret that I did not remember this report to follow up, even when it had disappeared from my inbox, but with the number of reports which come through our inboxes, it is impossible to remember every single report, especially after 10 days,'' she said.
SDHB chief medical officer Dr Nigel Millar said in a statement yesterday the DHB had apologised to the patient before her death, and had made significant IT changes to avoid it happening again.
``The Health and Disability Commissioner has made a number of recommendations relating to our processes for managing test results within our IT system, which we accept without reservation.
``Significantly, we have since moved to the South Island regional electronic system Health Connect South. This now provides a more transparent system for identifying and managing unacknowledged results,'' Dr Millar's statement said.
The Health and Disability Commissioner did not say which hospital the patient attended, but the SDHB confirmed yesterday it was Southland Hospital.