A man had a huge delay in being diagnosed with throat cancer in Auckland, having to wait months before being seen properly.
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In a Health and Disability Commission decision released today, commissioner Morag McDowell criticised the Counties Manukau District Health Board's booking systems.
About three years ago, a man in his mid-60s was referred to a specialist at the DHB because his voice was hoarse, but he only got a booking with a speech language therapist, not a clinician.
The therapist completed an imaging report and noticed there was an irregularity.
He was supposed to see a clinician within three months on the advice of the therapist, but that did not happen.
Instead, he was not followed up for 10 months.
He was eventually seen by a clinician, almost a year after his appointment with the therapist.
Soon after, he was diagnosed with throat cancer.
McDowell said the system was not clear enough to ensure good communication between clinicians and administrators.
"There was poor orientation for staff on making follow-up appointments," she wrote in her decision report.
She noted it was important to have a system in place that ensured more serious requests were prioritised over less serious ones.
"I would regard this as being a moderate to severe departure from an appropriate standard of care."
McDowell recommended the health board report back on the effectiveness of the changes it had implemented since, and said the board should use her report for staff training.
At her request, the board sent the man a written apology.
The speech therapist was also criticised, because she failed to ensure her imaging report was reviewed by a clinician, as it was outside her scope of practice to diagnose pathology.
The commissioner also said the therapist should not have identified the timeframe for the man's follow-up appointment without clinician input.
Since the events, the speech language therapist accepted the need for monthly clinical supervision for a year.
She had also taken action to improve her practice and sent a written apology to the man.