• Southland Hospital failed to identify lung cancer in a man despite him having more than five years of scans.
• Deputy Health and Disability Commissioner Vanessa Caldwell found Health NZ Southern breached the man’s patient rights.
• The man, identified as Mr A, was eventually diagnosed with stage four cancer and told he had limited time left.

A man was told he had terminal cancer after Southland Hospital failed to spot cancer developing in his lung over five years of scans and X-rays.

One of the doctors involved in the man’s care said later, “I am deeply sorry”, about the delay in his diagnosis.

In all, the man had nine CT scans or X-rays between May 2017 and October 2022. Follow-up action was taken only after a scan and X-ray in the final month.

The man’s sister raised concerns with the Health and Disability Commissioner (HDC) that abnormalities in chest images were not identified in 2017.

She said that follow-up scans between 2019 and 2022 revealed changes that were not followed up adequately, leading eventually to a diagnosis of Stage 4 cancer.

The man is identified only as Mr A in a report by Deputy Health and Disability Commissioner Vanessa Caldwell released on Monday.

Failed ‘significantly and repeatedly’

Through his lawyer, Mr A told the HDC that he had been failed “significantly and repeatedly” by multiple professional clinicians who had failed to spot the cancer developing in his lung.

He was left dealing with multiple secondary cancers, with lesions in his spine and other bones, as well as brain bleeds and effects on his liver and veins.

The report said that Mr A, a non-smoker, was diagnosed with stage four lung cancer which had spread to his spine after a 6.8cm mass was spotted in his upper right lung in October 2022.

He was advised that he had a life expectancy of six months to a year. However, the HDC confirmed that Mr A was still living in early March 2024.

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

His lawyer told the HDC that the “excuses” offered by Health NZ Southern in the man’s case - environment, working conditions and work pressure - were noted.

“With respect, that is not the patient’s fault,” the lawyer told the HDC.

“Multiple parties from different working environments, all of whom are deemed to be professional clinicians, failed [Mr A] significantly and repeatedly,” the lawyer said.

“[Mr A] and his family and friends are left wondering what his prognosis and outcome of treatment would have been, had the radiologists involved in his case been competent and had seen the visible lesion in 2017 and ensured that the doctor/s looking after him actually followed up and that his case was made a priority.”

Breach of patient rights found

Caldwell found that Health NZ Southern had breached Mr A’s patient rights in the care it provided him between 2017 and 2022.

“In my view, there were several missed opportunities by staff at Southland Hospital to identify Mr A’s malignancy and escalate his care appropriately,” Caldwell said.

“Several different clinicians involved in Mr A’s care failed to identify the abnormality [in his lung] and its evolution adequately, and conduct further investigations or surveillance in line with relevant standards,” she said.

The report said that an 18mm “nodule” was first spotted on Mr A’s lung in May 2017.

Mr A said the significance of the lesion was “missed” again in an X-ray in 2018, when it measured 3cm.

One of the doctors involved in the man’s care, identified in the report as Dr F, admitted he did not perceive “red flags” in Mr A’s case even after he reported developing chest pains in 2019.

A chest CT scan in December 2019 found a 27 by 11mm “opacity” in the lung but Dr F said this was “roughly stable” and similar to those noted on previous scans.

Further routine X-ray or CT surveillance was deemed not necessary.

In a response to the HDC, however, Dr F said there was now no question that further surveillance should have followed “as a minimum”, or a bronchoscopy and biopsy ordered in January 2020.

“Neither step was taken and a lung cancer was diagnosed only much later with unacceptable delay and with now a poor outcome,” Dr F said.

“All of this is more regrettable and I am deeply sorry.”

Caldwell said that there were “several missed opportunities” by staff at Southland Hospital to identify Mr A’s malignant cancer and escalate his care between 2017 and 2022.

She said these failures amounted to a breach of the Code of Health and Disability Consumers' Rights.

“In reaching this finding I have taken into account that several different clinicians involved in Mr A’s care failed to identify the abnormality and its evolution adequately, and conduct further investigations or surveillance in line with relevant standards.”

Call for written apology

Caldwell said Health NZ Southern should provide a written apology and a report on how it was implementing the recommendations of an “adverse event” review.

Health NZ Southern has been approached for comment.

In response to the HDC, it said that its adverse event review was completed in July 2024.

It recommended that the health agency consider a business case for a radiology registrar at Southland Hospital.

It also recommended a review of processes to reduce distraction, and a reconfiguration of the working environment so that the medical officer who was reading images could have “quiet protected time”.

It also recommended additional training in topics such as early-stage appearances of lung cancer.

It noted that work was going on to provide support to staff to ensure a “reasonable work-life balance to reduce stress and fatigue”.

Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.