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Delay in notification of CT colonography results (12HDC00203)
Download Delay in notification of CT colonography results (12HDC00203) (PDF 40Kb)
(12HDC00203, 21 June
General practitioner ~ Medical Centre ~ CT colonography ~
Tumour ~ Follow-up ~ Test results ~ Electronic reminder ~
An 81-year-old woman consulted a locum general practitioner at a
medical centre, complaining of tiredness. She had had a right
hemicolectomy for bowel cancer in the 1990s. Blood tests showed
that the woman had anaemia, and the locum GP prescribed oral iron
and referred her to the Surgical Outpatient Clinic at the public
hospital for a colonoscopy. The locum GP did not set a reminder on
his computer for the results of the colonoscopy.
A few days later the woman's whānau requested that the woman
instead be referred privately for a CT colonography. The locum GP
was not working that day, so the woman's usual doctor initiated the
referral. He noted the referral in the woman's clinical records,
but did not communicate to the locum GP the change in the woman's
management plan, and did not set a reminder on his computer for the
results of the CT colonography.
The CT colonography identified a tumour in the woman's colon.
She was not informed of this result of her CT colonography until
nearly four months later.
There were a number of contributing factors to the delay in the
woman receiving the result of her CT colonography: Neither GP
followed up their referrals; the radiology service sent the result
electronically to the GP at his old address at another medical
centre; that medical centre advised that the result was forwarded
to the GP at his current medical centre; the current medical centre
advised that the result was not received; despite contact from the
woman and her whānau asking after the result, staff did not follow
up the result; and the woman recalled that she was told by a staff
member that "everything was fine".
General practitioners who refer patients to a specialist have a
responsibility to take reasonable steps to follow up the referral.
It was held that the GPs and the medical centre did not take
reasonable steps to follow up their referrals. Therefore, the woman
did not receive services with reasonable care and skill, and the
medical centre and both GPs breached Right 4(1).
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