The male patient with a history of cancerous melanoma presented at Te Whatu Ora Southern in 2021-2022. Following an assessment by an orthopedic surgeon regarding pain in the man's left leg in late 2021, the doctor requested an emergency MRI scan to check for any relapse of cancer.

While the patient should have received an MRI scan within 31 days of the request, the scan was not performed until 20 weeks after the request was made, according to the case report. The scan showed metastatic cancer in the man's spine, which had caused spinal cord compression.

The report, published on 6 November, went on to state that Te Whatu Ora accepted that the failure to complete the man's MRI scan within an acceptable time frame and indicated a systemic failure.

It also stated that Te Whatu Ora Southern has taken steps since the incident. These include installing an additional MRI scanner at Dunedin Hospital, where the man received care, updating its policy so that staff have the necessary guidance for appropriate management of urgent referrals, and working with Te Aho o Te Kahu/Cancer Control Agency and Te Whatu Ora/Health New Zealand to explore methods for improved tracking of the progress of cancer patients.