Two reports of poor followup

FURTHER reports of scans not being followed up properly — including one resulting in partial blindness — have emerged in the wake of a finding by the Health and Disability Commissioner (HDC) of historic inadequate recordkeeping by the Southern District Health Board.

On Monday, the HDC released a report which found the SDHB failed to provide services to a patient with reasonable care and skill after MRI scan results which found a tumour in her head were not followed up for nine months.

Yesterday, the Otago Daily Times was alerted to two further cases of scans carried out in a public hospital which did not result in prompt followup action. The doctor involved in the tumour case was criticised by the commissioner for waiting until a followup appointment with the woman to tell her about it.

Both cases brought to the ODT’s attention involved the same doctor.

As HDC cases are anonymised, it is not known whether that doctor was involved in the latest two cases.

One reader, who did not wish to be named, said a scan found a tumour in his head but he received no followup communication from his doctor.

His condition was later successfully treated.

‘‘Everyone makes mistakes, I’ve made plenty . . . but if it is the same guy this is the third time that this has happened, with varying results,’’ the man said.

‘‘If you have someone who has experienced teething issues with communication, and given the industry he is in they have a range of impacts, he or she should proceed in a way to deal with a known problem.’’

The second case involved a man whose scan results were not reported back to him. He eventually obtained treatment, but too late to save the sight in one eye.

‘‘Was it pandemic at that point, and has it subsequently changed because practices have been improved?’’ the man asked.

The man said he was not on ‘‘a personal crusade’’ but was concerned after seeing the ODT story that other patients might be in a similar situation.

The SDHB has apologised to the woman whose treatment was reviewed by the HDC, and has since put a new computerised medical records system in place.

‘‘The current system, which electronically provides results to clinicians, is a substantive improvement on the old paperbased system,’’ SDHB chief medical officer Nigel Millar said.

‘‘No electronic system however removes all aspects of risk.

‘‘Southern DHB, like other DHBs, has had instances where regrettably there has been failure to follow up on a patient who has had a significant diagnostic result. ‘‘Thankfully this is not common.’’ All results were now made visible electronically when completed so there could be no loss of paper reports, Dr Millar said.

‘‘We are confident that the clinicians are notified of the results . . . we invite any patients with concerns to contact us directly to discuss any questions they may have.’’

On details provided, the SDHB did not believe the same specialty team was involved in all three cases.