Normally a patient undergoing surgery like this would have CT scans and X-rays done and reviewed a week or two before their surgery was to take place.
In Mr A's case machine failure, system failure and human error meant that these scans weren't done until five days before his surgery and weren't seen by the surgeon until the day of his liver resection.
The surgeon was looking for any changes in the man's liver since his last scan four months earlier.
He wasn't looking for cancer that had spread to the lungs.
If he'd noticed the nodules on Mr A's lungs he told the Commissioner, he wouldn't have proceeded with surgery.
Instead Mr A would have been fast-tracked to palliative care instead of undergoing liver surgery that would ultimately be pointless.
His daughter said that her father made an effort to get the best care possible for himself but "fell through what seem to be institutionalised gaps in our health-care system".
She said that the overlooked scan results of the lung lesions and abdominal mass were the "final act in a litany of oversights that resulted in an unnecessary surgery", and that he was in a vulnerable position and put implicit trust in his health providers.
Mr A died in 2020.
Deputy Health and Disability Commissioner Rose Wall said if the lung metastases visible in preoperative imaging had been recognised before surgery, this would have prevented the man's liver resection surgery from going ahead, and put him on a palliative care pathway sooner.
"The report highlights the importance of having guidelines and policies in place to facilitate careful, thorough, and timely reporting of preoperative imaging," she said in her findings.
She recommended that the two District Health Boards involved should apologise to the man's family and to implement a policy to make sure preoperative imaging should be reviewed and casemented before surgery.
