A teenage girl died after a radiologist failed to spot a lesion in an MRI scan, a Health and Disability Commission report released today shows.

The case has prompted Commissioner Anthony Hill to order an independent review of the radiology service, including rostering and staffing levels, because of poor work conditions, which contributed to the error.

Hill found the radiologist breached the Code of Health and Disability Services Consumers’ Rights for missing a lesion in the girl’s scan eight months before it was finally discovered.

After being diagnosed with high-risk medulloblastoma, a cancerous tumor in the brain, in 2007, the girl, who cannot be named for privacy reasons, had neurosurgery at the age of 10.

Then, for the next six years, a number of MRI (magnetic resonance imaging) scans showed no evidence of residual or recurrent tumours. An MRI in August 2014 showed no change, she was told.

But eight months later the girl, now 17 years old, went to the emergency department after getting headaches and becoming unsteady on her feet.

A new MRI identified a lesion and an analysis of the previous scan confirmed the lesion had been there but not identified by the radiologist.

The radiologist found the mass was “much more extensive than it was in August 2014”.

A biopsy confirmed the medulloblastoma had returned and the tumour was inoperable.

The young woman was referred for hospice care and died the following year in 2016.

Hill said the lesion would have been apparent to most radiologists who regularly report on MRI head studies.

Hill found that the radiologist failed to provide services with reasonable care and skill.

The radiologist accepted the lesion was present and visible in the previous scan and that he had missed seeing it. He apologised to the young woman’s family, under Hill’s recommendation.

The radiologist said it was not possible to have a second person check each scan because of the very heavy workload. At the time, radiologists were working under an “unmanageable” workload because five people were on leave.

The radiology service said radiologists were encouraged to seek further assistance from colleagues should they feel the need to have a second opinion but acknowledged that second readings were not mandatory best practice at the radiology service or in New Zealand.

Hill considered that this case identified some areas for potential improvement in the radiology service’s collaborative working relationships with radiologists and the DHB.

He recommended that the service obtain an independent review including of its rostering structure and staffing levels.

Source: NZ Herald

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