A woman died from cancer after poor care from two doctors at the same medical clinic, the Health and Disability Commission has found.
The woman in her 60s had a delayed diagnosis of woman's metastatic oesophageal cancer and later died in hospital.
According to the Health and Disability Commissioner, the woman attended consultations with two different general practitioners at a medical clinic in the same month. The name or location of the clinic isn't provided in the commissioner's report.
On her first visit, she presented with symptoms including fatigue, loss of appetite, 7kg weight loss over the previous two months, and feeling cold.
The first doctor, a part-time locum, requested blood tests and an ultrasound scan of the woman's liver.
In a reply, the radiology department prioritised the woman as "category C", which indicated a waiting time of 30-38 weeks but advised the doctor to review the prioritisation to ensure it was clinically appropriate.
However, that letter was sent to another clinic the part-time locum had worked. It was then posted to the correct clinic but the doctor does not remember seeing it.
After her symptoms deteriorated, the woman went back to the same medical clinic.
The second doctor did not perform a physical examination or record any vitals signs. He prescribed some drugs and had planned to review woman again in four to six weeks' time and repeat blood tests.
Five days later, the woman went to the emergency department at a public hospital as her condition had worsened further.
She was diagnosed with metastic oesophageal cancer and died a few weeks later.
In the review, the second doctor claimed he told the woman she should be admitted to hospital that day, but the woman refused because it was a public holiday. But the woman's husband, who attend the appointments, does not remember this advice.
The Aged Care Commissioner, Carolyn Cooper, found the care provided by the second doctor fell below appropriate standards and breached the code of conduct.
It's been recommended that the second doctor apologise to the family for the failings, while the medical clinic has been advised to implement a new management process for the filing of documents.
The clinic has also been told to consider a new system for the appropriate management of locums to ensure continuity of care.
In 2021/22 the Health and Disability Commissioner made 402 recommendations for quality improvement and providers complied with 98 percent of those recommendations.
