Health and Disability Commissioner Anthony Hill reported that in Auckland City Hospital a patient died because faxed test result was too faint to read. Unfortunately, there were no request for a legible copy.
The man saw his GP in July 2009, complaining of chest pain on exertion. An exercise test indicated he had “significant coronary artery disease that required urgent attention”. One doctor reported patience’s exercise stress test results were “grossly abnormal”, but in the referral letter to Auckland City Hospital’s cardiology department, the result was described as “positive”. The test result, printed on pink paper, was faxed – with the referral letter – to the hospital but came out too faint for the triaging cardiologist to read.
DHB 2 officials told the commissioner of changes that had been made, including encouraging doctors to photocopy the pink exercise test results on to white paper for faxing.