Damning report on HB Radiology Service

‘Decapitated system’ … ‘culture of learned helplessness with a belief amongst staff that clinical issues and risks are known but no resolutions offered’ … ‘a system waiting for actual harm to occur before it does anything’ … and clinicians enduring more than a decade of poor performance, frequent workstation crashes and unsafe processes within the radiology department. 

These are just some of the damning observations noted in an external review of Te Whatu Ora Te Matau a Māui Hawke’s Bay Radiology Service.

The 35-page review report, completed in April was released by Te Whatu Ora – Health New Zealand to BayBuzz on Wednesday, following an Official Information Act request. Here is the full report.

The report was released to the NZ Herald on Monday night.

The report was originally requested by other media organisations in May, but declined on the grounds it would identify a whistle blower – i.e Dr Bryan Wolf.

Back then, Te Whatu Ora’s legal advice was that the Protected Disclosure Act had primacy over the OIA, and they needed to take all necessary steps to uphold the protected disclosure to avoid the whistle blower’s identity from being revealed.

Since declining to release the report, the whistle blower, Wolf, has provided significant information to the media, and Te Whatu Ora – Health New Zealand sought and received permission to release the review report from him.

The report had 18 recommendations for Te Whatu Ora Te Matau a Māui Hawke’s Bay Radiology Services.

Of the 18 recommendations five have been implemented/completed, 11 are in progress and two have been accepted in principle.

The recommendations broadly relate to stabilising the radiology information system and having it ready to perform as a regional system; process steps related to e-order and sign off of diagnostic results; wider considerations related to clinical governance, leadership and culture; and progress on implementing an electronic health record (itself a longer-term consideration).

The staff interviewed for the report were – Bryan Wolf, Consultant Radiologist; Kai Haidekker, Head of Department Radiology; Michael Mackrill, PACS Administrator; Crispin Porter, Clinical Director Acute Medical Services & Chair Health Services Clinical Governance Board; Simon Harger, Head of Department Emergency Department; Anne Speden, Executive Director Digital Enablement; Angela Fuller, Radiology Manager; Paula Jones, Service Director Acute and Medical; Chris Ash, Interim Lead H&SS; Robin Whyman, Chief Medical and Dental Officer; Karyn Bousfield-Black, Chief Nursing Officer/Director of Patient Safety & Quality.

Discussions with the staff described a system in which patient safety issues were evident.

One interviewee said it felt like the “system wants an actual harm to occur before it does something”.

Some of the examples given around patient safety included:

• Issues with test results, unacknowledged and missing results
• Delayed reporting of a healed carotid artery dissection and continuation on anticoagulants unnecessarily
• Work arounds with potential issues, including GPs being unable to access results 
• Waiting four hours for the reporting of acute CT, and 
• Reports coming through once patients had transferred from ED to Wellington for care.

In relation to harm events the report writers acknowledged knowing: 

• Harm had been identified and documented
• Inadequate responses left staff feeling demoralized, burnt out and helpless 
• Work arounds had been created which led to increased workloads for staff, and 
• Harm events that are unreported were not referred to ACC.

The report mentioned staff welfare and safety issues saying, “It cannot be overemphasized that there are issues of clinician burnout and significant stress, leading to health and safety and overall wellbeing concerns for individuals. Support is required to these individuals and Te Whatu Ora as an employer has a duty of care to ensure an adequate response is provided.”

Furthermore, the report mentions multiple technical issues being raised in the reports and by other staff during the panel visit to Te Matau a Māui Hawke’s Bay on February 4, 2023.

The issues included prior studies not being visible to reporting radiologists, radiology reports not being delivered to referrers, with at least one case where a critical report was not delivered to the referrer leading to a 16-month delay in the diagnosis of malignancy.

Te Whatu Ora Te Matau a Māui Hawke’s Bay were approached by BayBuzz for comment on the report and recommendations but did not provide one.

Public Interest Journalism funded through NZ On Air