The Southern District Health Board (SDHB) is undertaking a full review of its processes after staff failed to diagnose a woman with rectal cancer, despite the woman presenting herself to the emergency department three times with rectal bleeding.
In her report on Monday, Health and Disability Commissioner Morag McDowell said there were a "number of deficiencies" in the care of the woman across her three visits to the emergency department.
She found there was no specific follow-up to identify the cause and source of her bleeding, test results were recorded incorrectly, and the woman's family history of bowel cancer was not explored by any of the clinicians.
"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," said McDowell.
"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."
McDowell recommended SDHB share the case with staff as an example of the importance of critical assessment and undertaking adequate examinations, and encouraged the health board to teach junior staff on what constitutes a rectal examination, and its importance and limitations.
The SDHB said that as a result of the concerns around processes for referrals, the health board is undertaking a full review of its processes to ensure referrals are handled in a more timely and transparent manner.
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