A radiologist who missed a lesion on the x-ray of a patient who ultimately died will have to write a letter of apology and have his files randomly and independently reviewed.
The woman visited her GP in 2013 with a history of severe pain in her lower hips and back and was sent for an x-ray, which uncovered multilevel chronic disc degeneration.
But a report by the Health and Disability Commissioner has revealed the radiologist, who had an injury slowing down the speed of his work in an understaffed department, missed a L2 lytic lesion.
The woman continued to experience pain, was provided mobility and home aids and prescribed opiates.
It was eventually identified along with significant spinal cord compression after a further x-ray and MRI nine months later, resulting in a diagnosis of multiple myeloma requiring spinal stabilisation surgery.
Because of a difficult recovery she was sent back to hospital where she acquired pneumonia and subsequently died.
"It was recommended that Dr B provide a written apology to Mr A, and have an independent radiologist peer perform a review of a random selection of his reports completed in the last 12 months," a report by Health and Disability Commissioner Anthony Hill, released on Monday, said.