Health New Zealand Breaches The Code For Delayed Cancer Diagnosis 23HDC00401

A report released today by Deputy Health and Disability Commissioner Dr Vanessa Caldwell has found Health New Zealand | Te Whatu Ora breached the Code of Health and Disability Services Consumers’ Rights (the Code) for a significant delay in a woman’s cancer diagnosis.

The woman, known to be at high risk for liver cancer due to a liver disease, had undergone regular scans until 2019 when this surveillance was stopped. Two years later, she presented to the Emergency Department with nausea, upper back pain, and other symptoms. She was diagnosed with liver cancer and sadly passed away after receiving palliative care.

Dr Caldwell concluded that Health New Zealand’s system was deficient for failing to continue the woman’s liver ultrasound scans and failing to book an outpatient appointment with the gastroenterologist in a timely manner.

Health New Zealand had a duty to ensure that the services provided to the woman complied with legal, professional, ethical, and other relevant standards, Dr Caldwell said.

The woman did not receive coordinated services that ensured a continuation in her care. This failed to comply with Health and Disability Service Standards and breached the Code.

Dr Caldwell considered the most significant factor in the delay of the woman’s cancer diagnosis was due to changes made to the radiology referral systems without the appropriate safety-nets being put in place to identify patients who were pre-scheduled for appointments.

"I am particularly concerned that when it was determined that surveillance ultrasound scans would require a new referral, there appears to have been no consideration as to how this might pose a risk to patients requiring new referrals for repeat scans to be generated, and no thought to develop a plan as to how to mitigate this," Dr Caldwell said.

Dr Caldwell did not consider it the sole responsibility of the referrer (the gastroenterologist) to make new referrals for all patients under surveillance.

"A system with safety-netting (eg, a message to GPs about the change) should have been in place to support him to do this."

Dr Caldwell was also concerned that the woman’s six-monthly follow-up outpatient appointment with the gastroenterologist was not booked, due to a process error in the Outpatients Appointment Office.

She said this was a missed opportunity to identify that the woman was overdue for her surveillance scan, and the recommended MRI follow-up could also have been actioned.

Dr Caldwell offered her sincere condolences to the woman’s son and wider family and acknowledged the impact of the delayed diagnosis on the family.

Dr Caldwell made several recommendations for Health New Zealand, outlined in her report.

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