DHB to apologise over death
A woman wasn’t told she had cancer for more than three years before it killed her, a report has found.
The Health and Disability Commissioner has ordered the Waikato District Health Board to apologise for the woman’s death.
In 2009, the 46-year-old woman’s appendix was removed after she suffered from abdominal pain. A lab report uncovered cancer of the appendix but neither the woman nor her GP was told. The cancer was not diagnosed until 2013, by which point it was too late to treat.
The woman’s GP referred her to hospital again with abdominal pain in 2012. Hospital staff failed to review the 2009 report.
She was put on the list for a colonoscopy, wait time two to six months. But her condition deteriorated, she began to lose her appetite and was vomiting.
Five months later, the colonoscopy was cancelled and she was referred to a gynaecologist.
At this stage, a doctor failed to review the 2009 report, deciding the pain was likely caused by a ovarian abscess.
A planned scan three months later was delayed by a further four months. The results were thought to show endometriosis, an inflammatory disease of the uterus. Her condition continued to deteriorate, she was unable to eat and lost weight. But she was discharged from hospital after another scan failed to identify any disease.
A subsequent colonoscopy revealed a possible recurrence of the cancer but staff failed to understand the prior diagnosis had not been communicated.
Over 14 months after she was readmitted with abdominal pains, a doctor identified the 2009 error but did not inform the woman of her condition for another two weeks. She was told of her cancer diagnosis after a biopsy found secondary cancerous growths.
Commissioner Anthony Hill found the junior doctor who first identified the cancer in 2009 failed to notify the surgeon, and the health board had no system in place to review results.
Hill said this was the primary error which resulted in the failure to appropriately care for the woman. The Waikato DHB had sufficient information to correctly diagnose her, but a series of errors exacerbated the failure. ‘‘The effect of this was that [the woman] remained unaware of a potentially lethal tumour until after it has metastasised ... The entire system let [the woman] and her family down.’’
Hill was critical of two doctors: one who failed to review the 2009 results and one who failed to tell the woman of the missed results when he became aware of them in 2013. ‘‘I am also very concerned that Waikato DHB claimed the outpatients ‘slots’ are only 10 minutes for patients.
‘‘This is a ridiculously short amount of time to elucidate a complex problem such as that presented by [the woman].
‘‘Waikato DHB should also be reminded that ‘busy-ness’ of doctors in practice is no defence for an error.’’
The commissioner recommended the health board conduct audits of patient records yearly to ensure its electronic results system worked.