A woman died soon after discovering she had lung cancer that had spread and that a hospital doctor had failed to follow it up.
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The Health and Disability Commissioner, Anthony Hill, said in a report today that the IT system used by the Southern District Health Board had allowed test results to disappear from view in a clinician's inbox, allowing it to go unrecalled.
He said it began when the 66-year-old woman, who had been a lifelong smoker, went to a hospital emergency department in the district in 2013 complaining of a cough and chest tightness.
The doctor who saw her there - known only as Dr C - diagnosed chronic obstructive pulmonary disease with acute asthma and gave her nebulisers.
Dr C did not mention that an X-ray report was pending, however, so neither the patient nor her family doctor knew to look out for it.
Later that month, this report arrived in an electronic form in Dr C's inbox. In it the radiologist said a mass, or growth, measuring 15 by 10 millimetres had been identified and it recommended a follow-up chest X-ray or CT scan in six weeks' time.
Dr C was due to take leave for 10 days and decided it was appropriate to order the follow-up test when she returned. She did not acknowledge receiving the report, and once back from leave it was no longer visible in the memo tab of her inbox. Therefore Mr Hill said she "did not recall the report".
About 20 months later, the woman went back to hospital with a constant headache, right-sided weakness, poor coordination and having recently experienced up to 10 falls. A review of her electronic clinical history revealed the non-actioned X-ray report revealing the mass.
A further CT scan at this stage revealed that cancer originating from the lung had spread to her brain, and the woman, known only as Mrs A, was given palliative care and died a short time later.
The Southern DHB, which carried out a serious incident review, told Mr Hill that at that time clinicians in the emergency department were "unaware that once memos were opened/viewed in the memo tab, after 24 hours they would drop to the bottom of the queue, where they were no longer visible, regardless of whether they had been acknowledged".
The DHB said test results in a separate part of the electronic system, the unacknowledged worklist, would remain visible until acknowledged, and would not drop to the bottom of the queue after a day. However, ED staff were unaware of the distinction and only working in the memo tab.
Regarding her failure to recall the first X-ray finding, Dr C said that with the number of reports going through their inboxes, "it is impossible to remember every single report, especially after 10 days".
She added: "I did not fail to action an abnormal result, the disappearance of the result from my inbox, for reasons beyond my control, prevented me from completing this task."
Mr Hill said it was acceptable for Dr C to rely on the electronic system, although ideally she would have used "safety-netting strategies", such as calling Mrs A or her GP regarding the first test result and the need for another.
Mr Hill said the system itself was inadequate, however, and the DHB had breached patient rights by failing to ensure that its staff were adequately and appropriated trained to use the system for managing the results and reports they had ordered.
"There was clearly widespread misunderstanding within SDHB's ED regarding the functionality of the IT system, which clinicians should have been able to use easily and rely on. This failure resulted in Dr C not following up on Mrs A's X-ray report."
He said that following these events the DHB had checked all other radiology results that had not been acknowledged because of the same problem and, where necessary, had contacted patients were further action was needed. It had also implemented a new process to minimise the risk of a similar mistake occurring, and clinicians also now used the unacknowledged work list rather than the memo tab.
