Radiologists overlook 'clearly visible' lung lesion for 5 years, report reveals

Multiple radiologists have come under fire after missing a man’s growing lung tumor for more than five years. 

A new report from New Zealand’s Health and Disability Commissioner Dr. Vanessa Caldwell indicates that the man’s tumor was first visible on a 2017 CT scan that took place at Southland Hospital in Invercargill but was not identified by the reading radiologist at the time. It also eluded several other radiologists over a period of five years, despite being “clearly visible” on nine different imaging exams completed between 2017 and 2022, according to the report. 

Caldwell highlighted multiple factors that might have impacted the radiologists’ performance, including staffing issues, noisy working environments and a lack of peer review opportunities. This, plus a lack of proper communication with the patient’s referring provider after the tumor was identified, contributed to a substantial delay in diagnosis and treatment. 

By the time the man was diagnosed with advanced stage lung cancer, his tumor was double the size it was when it first appeared on imaging in 2017. His lawyer revealed that the cancer had spread throughout his body and that he is now struggling with other symptoms that negatively impact his day-to-day life. 

"We note within the provisional report some of the excuses offered by [Health NZ Southern] in respect of the environment, work pressure, working conditions, etc., that the radiologists had to work in. With respect, that is not the patient's fault ... We note that multiple parties from different working environments, all of whom are deemed to be professional clinicians, failed [the man] significantly and repeatedly," he wrote in response to the commissioner’s report. "[He], his family and friends are left wondering what his prognosis and outcome of treatment would have been, had the radiologists involved in this case been competent and had seen the clearly visible lesion in 2017 and ensured that the doctor/s looking after him actually followed up and that his case was made a priority." 

The commissioner accused Health NZ team of failing to give the man “an appropriate standard of care.” Following the investigation, Caldwell recommended that Health NZ Southern take steps to improve the working environment of its radiologists, create opportunities for more frequent peer reviews and establish a radiology registrar position to assist with communications.