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A patient presented to a private hospital emergency department following an injury. She underwent an x-ray and computed tomography (CT) and was discharged two hours later with a diagnosis of shoulder soft tissue injury with follow-up general practitioner (GP) review.
The formal CT report, finalised two days later, showed a soft tissue mass in the patient’s neck and recommended ear nose throat (ENT) review and follow up MRI. The reporting radiologist noted in his report that this was discussed with the patient’s GP who would organise follow up. Three ED discharge summaries were copied to the patient’s GP, with the third discharge summary containing the formal radiology report. The patient’s GP stated to the HDC that because there were no changes to the first two discharge summaries, he filed the third discharge summary without reviewing this as he thought it was a duplicate.
The patient presented to her GP a few days later as recommended by the ED and there was no mention of the CT. She presented to an accident and medical clinic two years later for an unrelated matter and was informed of her CT neck result.
The patient advised her GP and this was the first time action was taken for her neck mass. The patient was subsequently diagnosed with metastatic squamous cell carcinoma and complained to the Health and Disability Commissioner (HDC).
Medical Protection assisted our member (the GP) with his response to the HDC. We helped him convey that he had no recollection of a phone call from the radiologist as he would have taken care to act on this.
Unfortunately, the HDC found the patient’s GP to have been in breach, taking into account that the while the GP had no recollection of a call from the hospital, three discharge summaries were sent out with the last one containing this finalised CT report. The GP had already apologised to the patient and the HDC also required that he undertake an audit of 30 discharge summaries received by the medical centre, to confirm whether or not any recommendations and/or follow-up results had been actioned and complete a self-audit of his clinical records.1i
References
CT scan results missed on discharge summary — Health & Disability Commissioner (hdc.org.nz)
Transfer of Care and Test Results Responsibility – Health New Zealand | Te Whatu Ora
Casebook . Handling Test Results 19 May 2015.