Radiology staff in Hawke’s Bay were “exhausted” by defective technical systems that undermined the care they provided to patients for years before they were brought to light by a whistleblower, according to a damning review of the department.
Te Whatu Ora – Health New Zealand released the 35-page review on Monday night in response to inquiries by the Herald, after previously refusing to make the document public.
The national health authority reconsidered its decision to disclose the report after a senior doctor whose internal disclosures prompted the review accused Te Whatu Ora of a “conspiracy” to avoid public scrutiny.
The report, completed in April, details a host of serious technical, cultural, and governance problems in Hawke’s Bay’s radiology service that resulted in documented harm to patients and severely affected staff morale.
The report cited one case investigated by the Health and Disability Commissioner in which an unnamed man in his 70s was found by a CT scan to have a possible malignancy, but the results were not read by a clinician until more than a year later. He died of cancer soon after.
“Clinicians have endured more than a decade of poor performance, frequent workstation crashes, and unsafe processes within the radiology department,” the reviewers found.
At the centre of the problems was an IT system that was plagued with technical problems, including that prior patient studies were not visible, scans for different body parts of the same patient were not linked, and reports were not delivered to the clinicians who requested them.
Staff had so little trust in their IT system that they printed out reports and circulated paper copies, although this was risky because the was no way of verifying that they were delivered to the right place or read.
There are also problems with scans sent to an external provider, the review found. In one recent case, a paediatric patient was referred by the hospital’s emergency department for a CT scan of their head and cervical spine. But the radiology report came back with a report and images in different folders, which resulted in a delayed diagnosis of a cervical spine fracture.
One clinician told the reviewers, “There has not been a single day in 12 years without an IT issue related to this system.”
Another said it felt like a system that “wants an actual harm to occur before it does something”.
On Monday afternoon, speaking at the post-Cabinet press conference, Health Minister Ayesha Verrall said she has been advised by officials that she is aware of four cases that have been referred for further investigation, although sources familiar with the disclosures said that far more patients have been affected.
The reviewers urged Te Whatu Ora to undertake a full review to determine the extent of harm to patients caused by the unsafe practices it identified. It also recommended an assessment of other hospitals in the region to determine if they have experienced similar problems.
The review also found wider problems with Hawke’s Bay’s culture and governance, which meant that radiology staff developed a “learned helplessness” and did not escalate problems.
“This culture of learned helplessness extended to staff outside of the radiology department,” the report said. “There was a sense… that clinical risk and clinicians’ perception of this has not been adequately acknowledged within the organisation for some time.”
Problems were escalated to hospital management but there was a “lack of tangible feedback or acknowledgment of the seriousness of the issues being raised,” the reviewers found.
Staff commented that the system had been “decapitated” by a lack of local leadership and changes in organisational structure, which is likely to be compounded by the latest reforms.
The reviewers said they were so concerned about the impact the problems were having on staff that they raised it immediately with Te Whatu Ora’s senior medical executives after a site visit in February.
“It cannot be overemphasised that there are issues of clinician burnout and significant stress, leading to health and safety and overall wellbeing concerns for individuals,” it said.
The reviewers made 18 recommendations, including the immediate establishment of a working group to implement them. Last week, Richard Sullivan, Te Whatu Ora’s chief clinical officer, told the Herald the health authority is working through the recommendations.
It said it is making improvements including technical upgrades, better operating procedures, and a new CT scanner.
Sullivan said he has been assured Hawke’s Bay’s radiology systems are now “safe and stable”, although “we have got a long way to go” before they are optimal.
The review was commissioned late last year after a consultant radiologist, Dr Bryan Wolf, alerted Te Whatu Ora’s board and national leadership team to problems that he alleged could cause immediate harm to patients and staff.
As the Herald revealed on Monday, Wolf wanted the public to be made aware of the safety risks and was infuriated when the health authority refused to release it to a journalist under the Official Information Act in May.
He took the extraordinary step of writing to the Chief Ombudsman Peter Boshier asking for Te Whatu Ora to be investigated. “I believe this can now reasonably be labelled a conspiracy to defraud the general public of their knowledge and health,” Wolf wrote in one of two letters to the Ombudsman obtained by the Herald.
Te Whatu Ora denied deliberately withholding the information and said it refused the OIA request because of its obligation to protect whistleblowers.
Alex Spence is a senior investigative journalist based in Auckland. Before joining the Herald, he spent 17 years in London where he worked for The Times, Politico, and BuzzFeed News.
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