A man who had a tumour removed from his bladder at Nelson Hospital went on to develop terminal cancer after a post surgery appointment was missed.
Nelson Hospital sign (File image). Photo: RNZ / Nate McKinnon
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found Te Whatu Ora - Nelson Marlborough, formerly Nelson Marlborough District Health Board breached the Code of Health and Disability Services Consumers' Rights after administrative staff failed to action a follow up consultation with a urologist two to three weeks after the man's surgery.
More than a year later, the man returned to hospital experiencing discomfort and blood in his urine and he was diagnosed with terminal bladder cancer.
It was then discovered that his follow-up appointment had not been booked in after his surgery in the previous year.
Caldwell found there were not robust systems in place to minimise the risk of errors in arranging important follow-up care, which was the responsibility of a healthcare provider.
She said the results of tumour biopsies was information a reasonable person would expect to receive.
"Patients are trained to consider 'no follow-up as no issue' with test results so it is vital that good systems are in place to ensure patients are followed up when test results show anomalies."
The man, who was in his early 60s at the time, had his bladder removed but the cancer had advanced and spread to his lymph nodes. He was given two years to live.
Caldwell said it was also critical the man was not notified about his histology results which contained serious findings of the fast-spreading cancerous tumours.
His terminal cancer could have been preventable had the man received timely follow-up and appropriate treatment postoperatively.
Te Whatu Ora - Nelson Marlborough accepted it failed to provide appropriate follow-up care to the man after his procedure by failing to make an outpatient appointment with the urologist.
Caldwell recommended the health board provide a written apology to the man and make changes to its discharge process for day stay unit patients.
Te Whatu Ora - Nelson Marlborough has since made a number of changes to its discharge and follow-up processes, including a review of policies, procedures, and guidelines to ensure they were adequate to prevent patients falling through the gaps.
It has also implemented software last December that allow clinicians to complete electronic operation notes that are automatically uploaded to clinical records, and directly notifies the respective secretaries of the need for follow-up.
Caldwell said she was pleased to see the systems improvements and changes which would lead to positive change and improved service delivery for future patients at Nelson Hospital.