In a recent report by the Health and Disability Commissioner, it was revealed that the negligence of a sonographer and radiologist led to significant repercussions for two families due to missed diagnoses in unborn babies. These incidents, occurring in 2021 and 2022, underscored the critical importance of providing medical services with the utmost care and expertise.

The first case involved the failure to detect congenital pulmonary airway malformation (CPAM) in a fetus, a condition that was only identified by another radiologist later on. This delayed diagnosis resulted in the necessity of removing the baby’s lung after birth, with the unfortunate consequence that more of the child’s lung tissue could have been preserved if the issue had been recognized earlier. The Health and Disability Commissioner’s findings highlighted several shortcomings in the sonographer’s scans, indicating suboptimal image quality and incorrect labeling, which ultimately contributed to the missed diagnosis.

Similarly, in the second case, signs of renal agenesis in a twin pregnancy went unnoticed despite multiple ultrasounds. Tragically, one of the twins passed away shortly after birth due to this undetected anomaly. The incomplete fetal anatomy imaging and inadequate scans throughout the pregnancy were indicative of the inadequacies in the services provided by the sonographer and radiologist.

Deputy Commissioner Rose Wall emphasized the responsibilities of the healthcare professionals involved, noting that the radiologist bore the overall responsibility for the quality of the ultrasound scans and should have provided feedback to the sonographer when necessary. The gravity of the situation led to the referral of the individuals to the Medical Council of New Zealand and the Medical Radiation Technologists Board for further assessment of their competence.

The profound and lasting impact on the families affected by these missed diagnoses underscores the need for maintaining high standards of clinical practice in the field of sonography and radiology. The delayed identification of critical medical issues during pregnancy not only affected the immediate outcomes for the babies but also had broader implications for the families and their communities.

In response to these incidents, the radiology service has implemented changes, including additional training for staff and a thorough audit of previous scans to prevent similar occurrences in the future. Both the sonographer and radiologist have taken steps to further their education, reflecting a commitment to improving their practices and ensuring the highest level of care for patients.

The cases serve as a stark reminder of the far-reaching consequences of medical negligence and the importance of upholding professional standards to safeguard the well-being of patients and their families. The lessons learned from these incidents will hopefully lead to enhanced protocols and practices within the healthcare industry to prevent such oversights and errors in the future.