Radiology crisis: Health and Disability Commissioner called for ‘urgent, immediate and transparent action’ in Hawke’s Bay

Commissioner Morag McDowell said she was alarmed about the safety risks brought to light by a senior doctor late last year.

The Health and Disability Commissioner (HDC) called for “urgent, immediate and transparent action” to remedy unsafe practices that harmed patients at Hawke’s Bay’s radiology service, the Herald has learned.

In a letter to Te Whatu Ora - Health New Zealand in June, Commissioner Morag McDowell said she was alarmed about the safety risks brought to light by a senior doctor late last year and the “lack of progress over time” to rectify them.

The commissioner said she was also concerned about long-standing systemic problems in the department – including a culture of “learned helplessness” among staff and a lack of action by hospital managers when they were alerted to the risks – and asked Te Whatu Ora to urgently provide details of the investigations and reforms it is undertaking in response to the revelations.

The regulator was tipped off to the worrying state of Hawke’s Bay’s radiology services by Dr Bryan Wolf, a consultant radiologist who late last year began escalating concerns about serious safety problems in his department to Te Whatu Ora’s board and national leadership team.

Last week, the Herald revealed Wolf’s disclosures had prompted the health authority to commission a review of Hawke’s Bay’s radiology service, which was completed in April and found a host of long-standing systemic deficiencies that caused staff burnout and harmed multiple patients.

At the centre of the problems was an IT system so defective that radiology reports were not delivered to doctors who requested them and clinicians were forced to adopt risky work-arounds.

Wolf wanted the public to be made aware of the safety risks, but the report was not published after it was completed and Te Whatu Ora refused to release it when it was requested by a journalist at RNZ in May.

Wolf was furious at the decision to withhold the report, and wrote to the Ombudsman’s office accusing Te Whatu Ora executives of a “conspiracy” to avoid public scrutiny and asking the Chief Ombudsman Peter Boshier to investigate.

Te Whatu Ora denies it deliberately sought to avoid informing the public about safety risks and said it followed legal advice when it denied the request from the journalist.

At around that time, Wolf alerted other agencies and watchdogs he hoped would intervene – including the HDC.

After Wolf provided the commissioner with some of his internal reports and a copy of the review ordered by Te Whatu Ora, McDowell wrote to Te Whatu Ora on June 12. The Herald has obtained a copy of that letter under the Official Information Act.

“In my view, the findings of the external review require urgent, immediate and transparent action to address the risk to patients from the current radiology IT systems used by the district,” the commissioner told Te Whatu Ora.

McDowell acknowledged the unsafe practices raised by Wolf dated back to before Te Whatu Ora was created last year, but added: “I am concerned by a lack of progress over time and that some of the issues may have been exacerbated by the current structure of the system.”

McDowell asked for a reply by July 3 that included Te Whatu Ora’s assessment of the review’s findings and recommendations and actions it was taking to improve the service.

The commissioner also asked for details of whether Te Whatu Ora was investigating the extent of harm to patients caused by the unsafe practices and whether hospitals in other regions were experiencing similar issues.

Te Whatu Ora chief executive Fepulea’i Margie Apa replied to McDowell on August 4 saying the health authority was implementing the report’s 18 recommendations under the supervision of a “national steering group”.

Apa did not answer the HDC’s questions about the extent of patient harm or whether other districts were having the same problems.

In several statements to the Herald over the past week, Te Whatu Ora has said it is “confident” other radiology services have not experienced problems to the same extent as Hawke’s Bay, even though some use the same IT system.

In Hawke’s Bay, four specific cases of patient harm which were mentioned in Wolf’s disclosures have been reviewed and referred to the HDC.

An audit is still being carried out to determine how many other patients were harmed, a spokesperson said.

Te Whatu Ora reconsidered its decision to withhold the document after it was contacted by the Herald two weeks ago in response to Wolf’s criticisms about non-disclosure. It released the full report to the Herald and RNZ on Monday last week.

In a statement, the HDC said it is giving Te Whatu Ora time to implement the review’s 18 recommendations, but will “continue to follow up on these issues”.

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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