The daughter of an Adelaide woman whose cancer diagnosis was delayed by three months says she is “sad and angry” a new system designed to prevent similar incidents has not been put in place.
Key points:
- Hazel Raethel was not told about biopsy results indicating she had cancer until three months later
- A review of her case recommended introducing a result tracking and notification function into the electronic medical records system
- The new function is yet to be trialled three years later
Hazel Raethel died in April 2020, aged 66, after undergoing major surgery to remove half her bowel and spending her last months in and out of hospital.
Ms Raethel first started experiencing stomach issues in early 2019 and was referred to the Royal Adelaide Hospital for an endoscopy and colonoscopy in August that year.
Biopsy results showed “inflammation”, according to medical documents, but Ms Raethel’s daughter Ruth Taylor said that was the only information her mother received following the procedures.
Later that year, Ms Raethel was admitted to a different hospital with severe abdominal pain, and a “check” of her original biopsy results revealed she had adenocarcinoma.
“She just got sicker, and sicker, and sicker, and it’s been frustrating, because if she’d known sooner, she might have been able to combat it better,” Ms Taylor said.
“Humans do make mistakes, we are fallible, [and] things get missed because doctors are overworked.
“But we are the human face of their mistakes, my family is.
“The system that was supposed to help her let her down.”
Health authorities reviewed the case and apologised for the delayed diagnosis.
They said while it was likely Ms Raethel had incurable cancer at the time of the original biopsy, earlier treatment “may have been available for short to medium term benefit … and complications … may have been avoided.”
‘Solution’ still not in place three years later
The review into Hazel Raethel’s case recommended “introducing a result tracking and notification function into the electronic medical record systems”.
But almost three years on, a trial of the new system is yet to begin.
“[A] … solution has been selected and will be added onto SA Health’s electronic medical records system, Sunrise EMR,” a spokesperson for SA Health said.
“A prerequisite is that Sunrise EMR is updated first, and this is due to occur later this year.
“The add-on function to deliver results tracking will be piloted soon after that.”
The spokesperson said the system, called “Compass”, would allow doctors to “track and manage results” as well as “send automatic follow-ups” if results were not reviewed within a certain time frame.
“It will add an additional level of assurance that results are being looked at and followed-up by clinicians and will minimise the risk that they’re missed,” the spokesperson said.
“Once the pilot is complete and evaluated, Compass will be rolled out across all EMR sites.”
The electronic medical records system is now in place in metropolitan hospitals but is still being rolled out at regional and rural sites.
Ms Taylor said she was disappointed the system had not been upgraded.
“This has been going on for … years, and how many people have been missed?” she said.
“This should have happened two years ago, or three years ago, after mum’s case.
“The RAH did end up apologising and said, ‘We want to keep in contact with you’, but they haven’t.
“They’ve never fed back to me at all, which I find really distressing.”
The SA Health spokesperson said other measures had been put in place since Ms Raethel’s delayed diagnosis, to “mitigate the risk of test results being missed in the meantime”.
“Clinicians have been provided additional information about how they can best use the existing functionality within the Sunrise EMR system,” they said.
Results tracking ‘crucial’ in a busy system
The Australian Medical Association’s South Australian president, John Williams, said patient results tracking was a “crucial part of patient care”.
“There’s discussion on this at a high level all the time amongst doctors, just to make sure that we’ve got systems in place to make sure things aren’t missed,” he said.
“It would be far better if as many of those systems could be automated as possible — we want to reduce human error.
“It saves us time, but also there’s less chance of error if things are automatically alerted to us.”
Dr Williams said current systems, which relied on doctors to follow up, were “extremely complicated and time-consuming”.
“Someone has to regularly check those inboxes, make sure things are flagged, appointments are made and follow-up investigations are made,” he said.
“As there’s more stress on the system, the workload is high, the more we can automate things and offload work that clinicians need to do onto the [electronic records system], the better it’ll be.
“This slowness to change and to move and put things in place is a problem in our public health system.
“I guess we saw in COVID it was remarkable how quickly things did change, so there’s reason to believe that things can change quicker.”
South Australia’s Health Minister Chris Picton, who first raised concerns about Ms Raethel’s case while in opposition, said the results-tracking function should be a priority for the department.
“I am glad now that action is being taken, I’m concerned that it’s taken this long to happen,” he said.
“Electronic health changes do sometimes take a long time to do.
“I think we need to get onto this as a priority to make sure that what happens to Ruth’s family and what happened to Hazel doesn’t happen to any more families.
“I’ve asked the hospital to again make contact with Ruth and her family to talk her through what changes are now being made.”