Man dies after scalp lesion missed during scan delays terminal skin cancer diagnosis
Photo:
Gorodenkoff Productions OU / 123RF
A man died after a terminal skin cancer diagnosis was delayed due to a scalp lesion being missed during a scan.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the radiologist, who conducted an MRI scan on the man for an unrelated issue but did not report on a noticeable scalp lesion, failed to meet the level of care expected of a health practitioner.
The man developed a cyst on the back of his head in 2019 and went to a public hospital where he was treated and discharged, Dr Caldwell said.
An initial referral for further assessment was declined and a further referral was triaged as routine, with the man told the wait time could be six months.
In January 2020, he underwent an MRI for hearing loss, unrelated to the cyst, and a mass seen on the scan was not reported.
The man visited his GP and the hospital again the following month as the cyst was painful and increasing in size but he was treated and discharged with no further follow up.
He was reviewed by the ear, nose and throat service in March 2020 for hearing loss and a biopsy was taken for a suspected tumour on his scalp, which was confirmed to be a very rare skin cancer by a scan two weeks later.
An amendment was then made to the initial MRI report by another radiologist.
It identified a soft tissue mass measuring 4.8 x 2.7 centimetres on the left of the scalp extending from the skin surface to the bone, that a biopsy had identified as skin cancer.
The radiologist who performed the MRI scan said he regretted he had not identified the lesion when he reviewed the brain MRI, which he had been able to identify retrospectively.
The man had surgery to remove the lesion in April 2020, with further surgery in July 2020 and was then told his condition was terminal.
He made a complaint to the commissioner in 2021.
Independent clinical advice provided by neuroradiologist Dr Allan Thomas found the standard of the reporting of the MRI scan "was grossly below the standard expected" of a radiologist.
Dr Thomas said while attention was focused on the temporal bones and hearing neural pathways for this referral, he expected a lesion of such size to at least be mentioned with appropriate clinical follow-up action recommended.
The radiologist had since reflected on the case and had adjusted his reporting processes as a result.
Dr Thomas found the provider was reasonable and thorough in its response when it learnt a significant miss had occurred, and it immediately sought to have the study appropriately reported, information added and the relevant clinical teams informed.
Errors occurred in radiology reporting for a number of reasons, but training and adhering to processes helped to avoid them, Dr Thomas said.
The radiologist told the Health and Disability Commissioner he deeply regretted his oversight, which contributed to the missed diagnosis, and accepted the focus of his reporting of the MRI scan was too narrow, but he did not consider it to be a severe departure from the standard of care.
He was now extra vigilant about assessing the skin and all areas of his practice.
He had adjusted his reporting to include reviewing the skin on the scalp and surrounding tissue as the final part of his MRI brain reporting process.
The radiologist said he no longer undertook out-of-hours reporting when his attention could be reduced.
He said he was committed to learning from the experience to ensure the same mistake was not repeated in the future.
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