Health staff “missed opportunities” when diagnosing a man who later died of septic shock caused by metastatic colon cancer, the Health and Disability Commissioner has found.
In a report released on Monday, the Health and Disability Commissioner said widespread cancer was discovered, but only after the man had presented to the emergency department seven times with severe abdominal pain.
The man, in his 50s, had a history of schizophrenia and chronic thought disorder, and lived in a community residential mental health service.
Over a six week period, he went to the ED seven times with the abdominal pain, and was repeatedly diagnosed as having constipation as a result of an anti-psychotic medication. Each time he showed at the ED, he was diagnosed the same.
The HDC found each staff member who had treated the man had “failed to question the previous diagnosis” or “undertake further investigations until he underwent surgery to examine the abdomen”.
During the surgery the man was found to have widespread colon cancer with tumours causing a complete obstruction of the bowel. The man died of septic shock, which the HDC said was secondary to metastatic colon cancer.
Deputy Health and Disability Commissioner Vanessa Caldwell considered that there were “numerous missed opportunities by many SDHB clinicians” across his many appearances at the ED, to investigate the man’s symptoms further and reconsider his diagnosis when he failed to improve.
"The cumulative effect of these missed opportunities demonstrates a concerning lack of critical thinking and acceptance of the man’s unimproved condition by SDHB staff, attributable to the DHB as the overall service provider, said Dr Caldwell.
"I acknowledge that the man’s illness was metastatic, and that an earlier diagnosis many not have influenced the ultimate outcome. However, I note that an earlier diagnosis of colon cancer could have opened up opportunities for palliative care that could have led to a significantly different end to this man’s life."