Radiologist misread scans, delaying liver cancer diagnosis for two men

A radiologist could face disciplinary action after two incidents where imaging scans were misread, leading to delayed diagnoses of liver cancer.

Health and Disability Commissioner Morag McDowell​ found a radiologist breached the patients’ rights code concerning the care of two patients.

In one case, Southern District Health Board (now Te Whatu Ora) was also found in breach.

The first report concerned a man aged in his 70s​.

In November 2017​, he underwent an abdominal ultrasound scan at Southland Hospital to investigate pain.

The scan showed a mass in the left lobe of the liver, and it was recommended he have a CT in January 2018​. Incorrect scan protocol was used.

As a result, the radiologist who interpreted the CT scan “missed suspicious findings”, the report stated.

He reported the mass was not cancerous, and considered it was a haemangioma (clusters of blood-filled cavities), the report said.

However, a follow-up CT 12 months later (in January 2019)​ showed possible cancer that had started in the liver.

Later that January, the man underwent a chest CT to determine the stage of the cancer. This showed lung lesions suspicious of metastases (spread of cancer).

The man was diagnosed with bile duct cancer​. He underwent palliative chemotherapy, but died.

The doctor accepted he made an incorrect diagnosis of haemangioma in 2018, and in the report apologised to the man’s wife and family for their loss, “this error, and all the [difficult] times that [the man] went through during his treatment”.

“I can only reiterate how sorry I am that this occurred.”

McDowell found the radiologist in breach of the Code of Health for failing to provide services with reasonable care and skill.

She was critical the radiologist did not correct an incomplete CT protocol when he became aware that the imaging was inadequate, “which ultimately resulted in substandard interpretation of the CT scan”.

McDowell considered that this failure was an error attributable to the radiologist.

In the second case, a man in his 60s visited Southland Hospital’s emergency department in 2017​ with stomach pain.

An ultrasound showed multiple gallstones and a small liver lesion, the report stated.

He underwent several imaging procedures over the next few months to assess the liver lesion.

Following an MRI, the radiologist reported the lesion as a benign haemangioma, and the man received no further follow-up care.

In 2019​, he was readmitted to hospital with abdominal pain, and an ultrasound identified that the original liver lesion had increased in size “substantially”.

A multidisciplinary meeting found that the MRI read by the radiologist in 2018​ was consistent with liver cancer.

He was subsequently diagnosed with terminal liver and pancreatic cancer.

The doctor expressed his sincere apologies for the “errors when interpreting [Mr A’s] MRI scan”.

McDowell found the radiologist in breach for misdiagnosing the man’s liver lesion on the MRI as benign, when it was in fact suspicious of liver cancer.

She said this was an error that fell “significantly below the standard of care reasonably to be expected of a consultant radiologist”.

McDowell also found Southern DHB breached the code for an “unacceptable delay” in starting an internal investigation into the misread report.

The radiologist has been referred to the Director of Proceedings to determine if legal proceedings should be taken.

“His incorrect diagnoses of benign haemangiomas in both cases resulted in devastating outcomes for the consumers involved,” McDowell said.

The radiologist no longer works for Southern DHB.