The Health and Disability Commissioner has recommended that a Health Board take steps to better educate staff and perform audits after medical practitioners failed to treat a tumour that was discovered.

The patient was admitted to hospital after a car accident and was sent for a CT scan due to concerns about back injuries.

The scan showed that the patient broke his back in the accident, but that there was also a lesion in his lung. The Radiologist recorded the finding.

Although the lesion was recorded in some notes, and the family was told that it would require follow up, no steps were taken to investigate.

After receiving treatment for his back injuries, the man was discharged from hospital. Less than five months later, the man returned to hospital with slurred speech, facial droop, and weakness.

It was discovered that the lesion had spread to his brain. The patient died a short time later.

The Commissioner held that the staff at the hospital, by failing to co-operate to ensure quality and continuity of service, denied the patient the opportunity for early diagnosis and treatment, breaching his rights.

The Commissioner recommended that the Health Board perform audits on how incidental findings are handled, provide its new policy on incidental findings, create education materials about incidental findings and the risk of failing to follow them up, and provide an apology to the patient’s family.

It is important that medical practitioners regularly record findings and arrange treatment for all identified health issues, not only those that are relevant to the immediate presentation. Failure to do so may result in poor health outcomes for patients.

If there are concerns that medical practitioners have failed to appropriately follow up a finding or treatment, it is wise to speak with a professional experienced in the area.

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Christian Merten


Gender Equality
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