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Delayed diagnosis of lung cancer

07 June 2019

Mr U, a 60-year-old businessman, was admitted to hospital for repair of an inguinal hernia. A chest x-ray was requested by Dr F on admission as part of the routine preoperative investigations.

The x-ray showed an incidental finding of a well-circumscribed mass in Mr U’s left upper
lobe of the lung, and the reporting radiologist recommended further evaluation by CT
scan. However, Dr F did not review the chest x-ray or the report prior to surgery. He was
not the operating surgeon who ultimately undertook the procedure, and the operating
surgeon was not aware that the investigation had been requested. Postoperatively the
care of Mr U was handed over to yet another surgeon, Dr B, who discharged Mr U the same day, again without having reviewed the chest x-ray.

Seven years later, Mr U was admitted to hospital for sudden onset shortness of breath and chest pain. Bronchoscopy and a CT scan were carried out, confirming Mr U had small cell carcinoma of the lung. Mr U made a claim against Drs F and B, both Medical Protection members, and the hospital, alleging missed diagnosis of early lung cancer at the time of his hernia repair, resulting in a poorer prognosis from the disease.

Expert opinion

Medical Protection instructed an expert, who considered that the lesion identified on the original x-ray likely grew to become the cancer that was later diagnosed, and that Mr U’s prognosis would have been better with earlier detection and treatment.

The expert considered that Dr F’s involvement was to order the investigations on behalf of the operating surgeon, and Dr B’s involvement was reviewing and discharging Mr U postoperatively (when it would be expected that abnormal preoperative findings would have already been acted on or flagged for future action).

The expert was critical that no clinician involved had reviewed the x-ray despite several opportunities to do so, including in an outpatient follow up clinic held by Dr F shortly after the surgery. The expert also commented that there were systems failures on the part of the hospital, for example there was no system in place for clinicians to note whether or not an investigation had been reviewed and acted on, and ultimately concluded that these factors were the main cause of the delay in identifying the lesion.

Outcome

The claim was settled by the hospital with a contribution from Medical Protection, in view
of the expert's criticisms. 

Learning points

Although the expert considered there to be significant system failings on the part of the hospital in this case, a clinician should not assume that others will review and act on investigation results. In a hospital setting, it would usually be expected that the clinician
requesting the investigation would also review the results.

If the requesting clinician is aware they will not be the one to review the results, adequate handovers of patients should take place in order to highlight which investigations have been requested, and any results which are outstanding. 

Learning points

  • Although the expert considered there to be significant system failings on the part of the hospital in this case, a clinician should not assume that others will review and act on investigation results. In New Zealand, it would usually be expected that the clinician requesting the investigation would also review the results.
  • Adequate handovers of patients should take place between clinicians in order to highlight which investigations have been requested, and any results which are outstanding.
  • In New Zealand, it is very likely that all doctors involved – certainly Dr F and most likely Dr B – would be at least severely criticised by the HDC, as would the DHB if appropriate protocols and systems for following up on investigation results were not in place.
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