Te Whatu Ora Waikato failed to pass on critical information about a patient’s X-ray results, who later died of cancer, the Deputy Health and Disability Commissioner has found.

Dr Vanessa Caldwell released her decision on the case this afternoon, finding the body previously known as the Waikato District Health Board had breached the woman’s right to be informed as stipulated in the Code of Health and Disability Services Consumers’ Rights.

The patient’s general practitioner was also not told the result and the need for her to have follow-up scans.

The patient, only referred to in the decision as Ms A, was later admitted to hospital and diagnosed with metastasised cancer in her lungs, lymph nodes, liver and bones. Ms A died weeks later.

The issue began when Ms A visited her GP to check a lump on her neck. The doctor referred her for an ultrasound which found abnormal lymph nodes. An initial X-ray also found abnormalities.

Ms A’s doctor told her to have another X-ray in six weeks because it appeared her health problems were going away. The lump on her neck had shrunk and a cough she had had improved. The GP did not follow up on the repeat X-ray.

Caldwell criticised the GP for not following up, saying this was a factor in Ms A’s delayed diagnosis.

Four days later, Ms A returned to her GP due to upper back pain. Her doctor was concerned the pain could have indicated metastasised cancer in her bones and discussed her concerns with an oncologist registrar.

Another five days later, Ms A was admitted to the emergency department at a public hospital with pain in her back, lower chest and abdomen, nausea and a reduced appetite and urination.

Another X-ray was done. Doctors initially interpreted it as showing the lung nodule had not changed. The actual report received seven days later, however, showed nodules in both her lungs and recommended she have cross-sectioning imaging done.

Ms A was not told about this recommendation in the report, nor was her GP.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell. Photo / James Gilberd Photography Ltd

Caldwell criticised Te Whatu Ora Waikato for not having a senior clinician check Ms A immediately after this X-ray. Caldwell did acknowledge staffing numbers, a systemic issue, may have been at play.

She was readmitted to the emergency department months later and was diagnosed with advanced cancer.

An earlier diagnosis may not have saved Ms A, but it would have given her more time, Caldwell said.

“Te Whatu Ora had a responsibility to inform Ms A of the abnormal result that had been reported and the recommendation for further imaging,” Caldwell said.

“In addition, Te Whatu Ora should have either arranged the further scan, or explicitly communicated to the medical centre that this additional imaging had been recommended.

“This omission was a further factor that contributed to the delay in diagnosis... I do not accept that Ms A should have been expected to follow up the repeat chest X-ray herself, as suggested by Te Whatu Ora.”

Caldwell has recommended the GP and Te Whatu Ora Waikato write apologies for the problems she found in her decision. She also recommended the regional health board review its electronic results policy and train staff on this.

Raphael Franks is an Auckland-based reporter who covers breaking news. He joined the Herald as a Te Rito cadet in 2022.