A patient’s cancer diagnosis was delayed due to one hospital’s radiology referral system. The delay was said to have been a key component in leading to the eventual death of the unidentified patient, Mrs. A. In 2017, she began undergoing ultrasounds every 6 months, as she was susceptible to liver cancer. However, in 2019, according to results from a recently released investigation, those scans stopped simply because of a change in a hospital radiology referral system. In 2022, she went to the ER and by CT Scan was found to have terminal cancer, which then led to her death.

The investigation found that this hospital changed its system for managing radiology referrals in 2019. The new system accidentally stopped repeat requests for regular scans, so this patient’s follow-ups were never completed.

The new system required a new referral for each scan, but this was not managed correctly for this patient. None of the hospital staff checked to ensure patients who needed regular repeated scans were still receiving them. The report from the investigation found that the hospital should have had a checks and balances system to prevent issues like this from occurring.

The Health & Disability Commissioner recommended changes to improve how follow-up radiology visits are handled to prevent similar issues in the future.