The Health and Disability Commissioner has criticised Health NZ after multiple investigations and doctors failed to diagnose a woman with ovarian cancer.
A report published on Monday by the Commissioner found Health NZ failed at an organisational level for missing opportunities to earlier diagnose the woman and offer her treatment options such as having her reproductive organs removed.
When an MRI scan was finally undertaken it confirmed the woman, who was in her 50s, had stage four ovarian cancer and she passed away a few months later.
The woman was referred five times to the Northland District Health Board (NDHB) Gynaecology department between 2014 and 2019 by her GP due to consistent post-menopausal bleeding.
Deputy Commissioner Dr Vanessa Caldwell found despite many investigations over the years, no plan was put in place to address the woman's symptoms.
She added there were missed opportunities by multiple senior clinicians to consider the cause of her symptoms critically, undertake appropriate imaging, and manage the post-menopausal bleeding appropriately.
Dr Caldwell was also critical of Health NZ for not offering the woman the viable option to remove her uterus, ovaries and fallopian tubes.
Finally, in 2019, an MRI scan was done after the woman went to the Emergency Department (ED) to receive an iron infusion in preparation for surgery to remove a fibroid the following week. Fibroids are non-cancerous growths in the muscle layer of a woman's uterus.
While at the ED, the woman told the hospital she had a history of increasing sharp pain in her stomach that was radiating to her upper back and she had a fever.
She underwent a CT scan which showed a large pelvic mass that was highly suspicious of ovarian cancer. The woman then had an MRI scan which confirmed "probable stage four cancer with raised tumour markers", the report said.
The woman was diagnosed with stage four ovarian cancer and over the next couple of months she had three failed biopsy attempts and could not start chemotherapy due to a bowel obstruction.
After advice from the doctor, the woman's family decided she would not have chemotherapy and focus on comfort care instead. The woman died a few days later.
Deputy Commissioner Dr Vanessa Caldwell said the woman's recurrent presentations should have triggered re-evaluation and consideration of treatment options, including a hysterectomy and/or hormonal therapy, as well as opportunities to perform imaging, which may have resulted in an earlier diagnosis, were also missed.
"I am critical of the failure by multiple clinicians to consider the causes of the woman's symptoms critically, manage the post-menopausal bleeding appropriately, and undertake necessary imaging in the form of pelvic ultrasounds and/or CT scans," Dr Caldwell said.
The failures in care by Health New Zealand amounted to a breach of the woman's right to receive services of an appropriate standard and her right to be provided with information regarding treatment options.
"The missed opportunities to provide treatment information are attributable to multiple clinicians, and signify a failure at an organisational level, for which Health New Zealand is responsible," Dr Caldwell said.
"In my view, offering support only at the start and end of care is not a culturally responsive or appropriate approach, especially given the woman’s long-standing engagement with the healthcare system."
Dr Caldwell reminded Health New Zealand of the need for the service to be culturally appropriate and to be mindful of the timing of offering support throughout a patient’s journey.
Since the event, Health New Zealand has made a number of changes which included establishing a Northland-wide clinic in 2020 specifically for postmenopausal bleeding streamlining the assessment process and enhancing continuity of care.
Guidelines for unresolved postmenopausal bleeding have been developed as recommended by the Commissioner.
"We extend our sincere condolences to the whānau for their loss and understand how hard it is for whānau when there is a devastating outcome for a loved one," Health NZ Northland group director of operations Alex Pimm said in a statement to Newshub.
"Patient safety and quality of care are topmost priorities, and we are committed to continuous service improvement."
The Commissioner also recommended Health NZ provide a written apology to the woman's family and conduct an audit of patients who have re-presented to Health NZ Northland over the past 12 months with symptoms of unresolved post-menopausal bleeding.
