A woman at high risk for liver cancer died after her regular check-ups stopped in 2019. The woman had been under surveillance ultrasounds since 2017 and was diagnosed in 2022 after presenting with nausea and upper back pain.
Dr. Vanessa Caldwell found failures in continuing the woman’s care after Health New Zealand—Te Whatu Ora changed the radiology referral systems without appropriate safety nets.
She was concerned that no consideration was made of how this might pose a risk to patients requiring new referrals for repeat scans and no plan was made to mitigate this.
Caldwell suggested that a better system with safety nets, such as a message to general practitioners about the change, should have been in place.
A processing error also prevented the woman from booking her six-monthly follow-up outpatient appointments, which Caldwell said was a missed opportunity to identify that the woman was overdue for her surveillance scan.
The Health New Zealand district had completed an adverse event review, and Caldwell recommended that it provide evidence that those recommendations had been implemented.
She advised the district to establish a process for ensuring appropriate safety nets when new systems were implemented.
