Health New Zealand Breaches Code Regarding Open Disclosure Of Cervical Smear Results That Had Been Misread 23HDC00079

A woman who was not told for almost eight months that her early-stage cervical cancer had gone undetected twice during routine cervical screenings, said she complained to the Health and Disability Commissioner because she didn’t want what happened to her to be experienced by other women. Sadly, she went on to develop more advanced cancer.

Following an investigation into the woman’s complaint, the Health and Disability Commissioner found the woman’s rights under the Code of Health and Disability Services Consumers’ Rights (the Code) were breached by Health New Zealand.

In 2021 following the woman’s diagnosis of cervical cancer, and at her request, a retrospective review of her previous smear tests was undertaken which showed that smears reported as normal in 2017 and 2020 had in fact been misread and were abnormal.

Regrettably, it took nearly seven and a half months for clinicians to disclose this information to the woman and her whānau. It was accepted by Health New Zealand that this delay impacted the woman emotionally, physically and financially.

Ms McDowell said Health NZ had breached the Code of Rights, specifically rights 4(1) - the right to care of a reasonable standard and 6(1) - the right to information.

There was a lack of clear processes which caused confusion as to who had primary responsibility for disclosing the smear review findings, which was information a reasonable consumer could have expected in the circumstances.

There were also failings in the system regarding the initiation of retrospective reviews of smear tests following a cancer diagnosis, and further uncertainty regarding undertaking a serious event review, which only occurred following the woman’s complaint and, again, at her request. This ultimately delayed investigation, potential quality improvement measures, and open disclosure with the woman.

"Patients are entitled to an open, truthful and timely discussion about what went wrong and why. It ensures that people are at the centre of their care, helps people to understand what the consequences are for them and their ongoing care, and is the first stage in fostering a culture of learning to improve clinical care for the future." Ms McDowell says.

She did not breach Health NZ for the misinterpretation of the smear tests, as false negative results with the cervical screening testing used at the time were somewhat unavoidable. Fortunately, recent changes to cervical cancer screening has made it more effective and it is expected that the false negative rate will reduce significantly.

Health NZ has actioned all the recommendations set out in its serious event report. It is also developing new guidance for staff in open communication to help complex circumstances of open disclosure.

Ms McDowell has recommended among other things that Health NZ formally apologise to the woman and provide an update of the actions taken to put in place the new HPV screening programme at a local level.

"I take this opportunity to encourage all women, especially wāhine Māori, to get tested under the new HPV screening method and for all healthcare providers to tautoko (support) and manaaki (take care of) their participation in the screening programme."

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