Two district health boards have been found in breach of the Code of Health and Disability Services Consumers’ Rights after failures led to a delay in a patient being diagnosed with breast cancer.
According to a Health and Disability report released on Monday, the woman, who was in her 40s, developed a painful lump in her breast in 2018, which her doctors considered was likely to be breast cancer.
She was referred from the Wairarapa District Health Board to the Hutt Valley DHB for breast imaging and intervention procedures as her local DHB does not have a permanent breast specialist surgeon.
After a biopsy came back negative for cancer, a multidisciplinary team at the Hutt Valley DHB diagnosed the woman with plasma cell mastitis based on the imaging results.
A second biopsy was carried out more than two months later after her condition deteriorated, which showed inflammatory breast cancer.
The cancer was aggressive and the woman died from the disease in 2019.
Health and Disability Commissioner Morag McDowell criticised the Hutt Valley DHB for the woman’s initial diagnosis without questioning the biopsy result, which she said “did not accord with the imaging results, and that further imaging and biopsy was not recommended”.
McDowell also noted the lack of a sole clinician in charge of the woman’s care, which she said had contributed to the “lack of recognition” that the initial diagnosis was incorrect.
“The frequent change in clinicians made it difficult for any clinician to have a full picture of the progression of the woman’s condition,” she said.
"The woman’s care was affected by the lack of clarity as to which DHB and clinician had overall responsibility for her.”
McDowell said because "consumers have the right to co-operation among providers to ensure quality and continuity of service", both DHBs are “equally responsible for the delay in her diagnosis”.
She added that the lack of a clinical alert once the correct diagnosis was available was a “critical error”, and that Wairarapa DHB should have a system to "red flag" abnormal results to clinicians.
"WDHB had the information needed to make an accurate diagnosis and provide the woman with appropriate care, yet its system failed to ensure that the information reached the appropriate clinicians within an appropriate time,” McDowell said.
"This contributed to an unnecessary delay for diagnostic results in a time-critical situation. It is vital that DHBs have systems in place for alerting clinicians to abnormal test results.”
She recommended that the DHBs provide an update on the changes made in response to the woman’s death, and report on any further changes carried out. She also recommended that the Wairarapa and Hutt Valley DHBs provide a written apology to the woman’s husband.
Both DHBs have since made changes to their processes, with the Wairarapa DHB creating a new role to “maintain visibility and continue of care for General Surgery patients” across the country, as well as a red flag system for abnormal results into the upgrade of its patient records system.
The Hutt Valley DHB, meanwhile, is developing more comprehensive protocols and policies to improve its services, as well as facilitating critical discussions with the Wairarapa DHB in the care for breast patient transfer and management.
"It is encouraging that both DHBs have acknowledged the lack of clarity in their breast service and implemented changes to their processes, and put in place a number of initiatives to improve it," McDowell said.
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