– Woman with cancer diagnosis
– Cancer patient with scans stopped.
Accident – Death – Obituary News :
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A tragic incident has come to light where a woman with a high risk of developing liver cancer passed away due to the disease after not receiving the surveillance scans her doctor had ordered. This unfortunate situation occurred as a result of a new system for repeat referrals that was implemented by Health New Zealand Te Whatu Ora in 2019. Despite the doctor’s initial orders for surveillance scans, they were not transferred to the new system, leading to a critical oversight.
Missed Opportunities and System Failures
Furthermore, an error in the outpatient department resulted in a missed follow-up appointment with the specialist, which could have potentially detected that the woman was not receiving her recommended scans. The woman’s son raised concerns and lodged a complaint with the Health and Disability Commissioner (HDC), who found that Health NZ’s system was lacking and failed to continue the necessary surveillance scans for the woman.
The woman had been identified as being at a high risk of developing liver cancer after being diagnosed with a liver condition in 2011. Following this diagnosis, a gastroenterologist had recommended six-monthly surveillance liver ultrasound scans and follow-up appointments. Despite these recommendations, the woman’s surveillance scans abruptly stopped in 2019, with no continuity in her care.
Impact on Diagnosis and Treatment
In late 2022, the woman was referred to the emergency department by her GP due to symptoms such as nausea, fatigue, reduced appetite, and back pain. A CT scan revealed advanced liver cancer, and she was provided with palliative care until her passing. The missed surveillance scans and lack of follow-up appointments played a significant role in the delayed diagnosis and subsequent treatment.
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Lessons Learned and Changes Implemented
Following the HDC investigation, Health NZ Te Whatu Ora has committed to increasing communication with GPs regarding liver ultrasound scans, conducting an audit of the liver cirrhosis surveillance programme to ensure no other patients have been overlooked, and offering an apology to the woman’s family for the delayed diagnosis. These measures aim to prevent similar incidents from occurring in the future and improve patient care and safety.
While the outcome for the woman may not have changed with earlier detection, the situation highlights the importance of effective communication, follow-up procedures, and system checks in healthcare settings. By learning from this unfortunate event, healthcare providers can strive to enhance their systems and processes to better serve and protect patients in need.
Written by Hannah Bartlett, Open Justice Reporter
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– at risk woman dies from cancer after scans stopped
– woman dies from cancer after scans stopped.
