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Poor safety netting leads to a poor outcome in recent HDC case

A recent HDC complaint from a man whose cancer diagnosis was delayed by a systems failure highlights the complexity of the healthcare system – and how we must have processes in place to protect patients.

This case concerns the care provided to a man over 2021 and 2022. Following an assessment by an orthopaedic surgeon regarding pain in the man’s left leg in late 2021, the doctor requested an urgent MRI scan to check for any relapse of cancer as the man had a prior history of melanoma.

The accepted practice at the time was for a patient to receive an MRI scan within 31 days of the request. However, in the man’s case, the scan was not completed until 20 weeks after it was requested.

The eventual scan showed metastatic cancer in the man’s spine, which had caused spinal cord compression. The patient said: “This delay meant further spread of the cancer through my spine and organs, resulting in the current situation whereby the cancer is now not survivable.”

The then-DHB has subsequently put practices and process in place to mitigate this risk, and provided and apology to the man.

As systems change and evolve and workload pressures change from time to time one should stand back and check that you are confident critical tests will be acted on in a safe, timely manner and not be lost.

You can read the full case decision on the HDC website:


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