It showed blockages to two arteries and the narrowing of a third artery, as well as a significant incidental finding of a mass on the kidney.

The report said the mass was “suspicious for a renal cell carcinoma [a type of cancer] and warranted dedicated work-up if it had not been assessed previously”.

However, the man was not informed of the cancer until he received a letter to attend a urology clinic in September, and visited a doctor to find out why he had been given the appointment.

Once diagnosed, the man had his kidney removed and began treatment for metastatic cancer.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell said several contributing factors led to the “unacceptable” four-month delay.

“In my view, there were several missed opportunities to advise him of the results of his scan, but clinicians were understandably operating on the assumption that he had been advised as per a letter on file.”

Factors in the delay were a lack of attention paid to the mass by the doctor reviewing the results, the absence of a patient-centred process and a lead co-ordinating clinician, poor oversight of multidisciplinary team meeting tasks, and the absence of a clear escalation pathway with the radiology service, Caldwell said.

“Individually, some of the deficiencies in the care provided to the man may appear minor but cumulatively, they led to a poor overall standard of care,” she said.

The doctor who reviewed the results said he was primarily focused on the vascular findings and the need for surgery, and in this process, overlooked discussing the incidental findings of the mass on the kidney.

He expressed sincere apologies for this, and Caldwell recommended he review his practice and report back a written reflection of the changes made to his practice within three months of her report being released.

Caldwell also found there was a lack of agreement with the radiology service for the communication of test results.

Health NZ was alerted to the incidental finding by email.

The renal mass in the MRA was a significant incidental finding and it was well understood that emails on their own were not a reliable way to communicate urgent findings, Caldwell said.

She recommended Health NZ develop a process for ensuring patients were informed if they needed to follow up on their results, if they were not advised of them within two weeks.

An update on this process should be provided to her within three months, along with a review of Health NZ’s memorandum of understanding with the radiology service for significant and unexpected findings.

Health NZ said it had made changes since the complaint was made.

The radiology service now put results on to a database that automatically sends them for acknowledgment and sign-off, getting rid of the need for manual result entry, it said.

A lead co-ordinating clinician was also formally planned for “if or when a regional vascular surgery structure was to be implemented for the Northern region”, Health NZ said.

Caldwell asked for updates on the planned lead vascular clinician and a tracked action log for multidisciplinary team meeting tasks, including a clear line of responsibility, within the next three months.

She also recommended Health NZ provide a written apology to the man within three weeks of her findings being released.