Southern District Health Board (SDHB) demonstrated a clear pattern of poor care towards a woman who has since been diagnosed with rectal cancer, an investigation has found.
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The Health and Disability Commissioner has published a report outlining deficiencies and missed opportunities in the DHBs' follow-up patient care.
The woman was receiving chemotherapy for a relapse of lymphatic cancer when she presented with rectal bleeding three times to the emergency department between November 2018 and January 2019.
Rectal examinations were carried out each time and no masses were recorded.
A referral for a colonoscopy was reviewed by a gastroenterologist in late January 2019, but was not pursued for further investigation.
A few days later, her GP conducted another rectal examination and made an urgent referral to a private gastrointestinal surgeon and endoscopist.
The surgeon felt a significant mass on the rectal wall during an examination in early February and a colonoscopy showed a large mass.
The woman was later diagnosed with rectal cancer.
The deficiencies found by the commissioner included no specific follow up to identify the cause and source of the rectal bleeding, no repeat investigation or referral to outpatient services after inconclusive test results, and results from the first presentation being recorded inaccurately in the discharge summary.
The woman's family history of bowel cancer was not explored by any of the clinicians.
Commissioner Morag McDowell said SDHB breached the Code of Health and Disability Services Consumers' Rights.
"I consider the cumulative effect of these factors and missed opportunities demonstrates a clear pattern of poor care, attributable to SDHB as the overall service provider," she said.
"I conclude there were numerous missed opportunities by a number of SDHB clinicians across several presentations to assess the woman's presentation critically and coordinate the appropriate investigations, which had they been performed, would more likely than not have identified her rectal cancer."
She recommended the DHB shared this case anonymously with staff to highlight the importance of adequate rectal examinations, maintaining accurate patient records with staff including full medical and family history, critically assessing patients who present on multiple occasions, and teaching junior staff on good rectal examination.
The commissioner also recommended the DHB consider keeping specialists in the loop if any of their existing patients present to the emergency department.
DHB chief executive Chris Fleming said the DHB deeply regretted the missed opportunities for diagnosis.
"We have arranged to meet with the patient to sincerely apologise for our failures in provision of care. We acknowledge and regret that these failures will have caused significant distress for the patient and their whānau," Fleming said.
"We are working through the commissioner's recommendations - all of which we accept and will implement within the timeframes outlined in the report as part of our ongoing commitment to improving the quality of our care."