Critical delay in cancer diagnosis through unacceptable delay in MRI scan - 22HDC02308

This case concerns the care provided to a man by Te Whatu Ora Southern in 2021-22. The man had a history of cancerous melanoma. Following an assessment by an orthopaedic surgeon, regarding pain in the man’s left leg in late 2021, the doctor requested an urgent MRI scan to check for any relapse of cancer.

The accepted practice at the time was to receive an MRI scan within 31 days of the request. However, in the man’s case, the scan was not completed until 20 weeks after it was requested. The scan showed metastatic cancer in the man’s spine, which had caused spinal cord compression. The man said: ‘This delay meant further spread of the cancer through my spine and organs, resulting in the current situation whereby the cancer is now not survivable.’

Te Whatu Ora accepted that the failure to complete the man’s MRI scan within an acceptable timeframe indicated a systemic failure in its process, and on that basis agreed with HDC’s proposal that it be found in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights for the delay.

Te Whatu Ora Southern advised that since the events it has undertaken the following actions to improve its service:

An additional MRI scanner has been installed at Dunedin Hospital (where the man received care), which has resulted in an improvement in wait times for urgent MRI scans, with the average wait time as of March 2023 being 4-6 weeks (down from 15-20 weeks at the time of the man’s care).

• It has updated its ‘Management of Referrals Radiology’ policy so that staff have the necessary guidance to ensure appropriate management of urgent referrals.
• It is working with Te Aho o Te Kahu|Cancer Control Agency and Te Whatu Ora|Health New Zealand to explore a digital solution to improve tracking of the progress of cancer patients through their diagnosis, treatment, and surveillance activities.

Dr Caldwell recommended that Te Whatu Ora Southern provide a written apology to the man, and provide HDC with a progress report on the development of the above digital solution, a copy of its updated referrals management policy, and an update on its current wait times for an urgent MRI.