A former prisoner at Auckland Region Women’s Corrections Facility (ARWCF) was diagnosed with colon cancer after prison staff failed to inform her of abnormal test results.
The Department of Corrections staff involved have been criticised by Health and Disability Commissioner Vanessa Caldwell.
The woman, who is in her 30s, went to a nursing appointment at the prison after saying she had blood in her stool.
The medical officer knew of the positive test result the day it was returned and booked the woman for the first available clinic appointment, but she was released from prison prior to the appointment.
The health service found out about the woman's release a week later. Corrections didn't contact the woman about her test result and she wasn't provided with her abnormal test result until over two years later.
The woman was then diagnosed with advanced colorectal cancer.
As a result, Caldwell found the Department of Corrections in breach of the Code of Health and Disability Services Consumers’ Rights (the Code).
Caldwell also found corrections' processes for ordering tests and follow up of abnormal results was inadequate and their systems failed to ensure the health service were informed of the woman’s release, or that the woman was told she needed to see a doctor once released.
The Code requires corrections, as a healthcare provider, to ensure health services are provided to prisoners to an appropriate standard.
Caldwell said there were several other issues with the woman’s care, which were partly due to the inadequate policies and procedures at corrections.
"There was a lack of effective communication between the different teams within corrections, namely the health service and custodial staff. As a result, the health service was unaware the woman was to be released, and therefore an earlier appointment was needed.
"Had the health service been informed of the woman’s release, at the very least she would have been provided with a discharge summary noting her abnormal result and the importance of follow-up in the community," she said.
Caldwell said corrections didn't provide medical treatment that was "reasonably necessary" for the woman, and the standard of health care she received wasn't "reasonably equivalent" to the standard of health care available to the public.
"I therefore consider there was an overarching service failure in this case," she said.
As part of the recommendations, Caldwell suggests corrections provide the woman with a written apology.
She also recommended they provide the Health and Disability Commissioner with an update on the changes made since the incident.
The update would include the review and development of its policies; report on the current wait times in the health service at the prison and the further actions taken to ensure patients’ health needs are prioritised appropriately.
An audit of prisoners who have been released should also be completed, to check whether the appropriate steps were taken in relation to their discharge summaries and health information.
In a statement on Monday, Deputy Chief Executive Health Juanita Ryan apologised for the incident.
She said on this occasion, the systems and processes in place let the woman down and "for that we unreservedly apologise."
Ryan said since Caldwell's recommendations, a number of changes have been made to strengthen processes to ensure inmates have detailed health information on release, as well as any community follow-up that may be required.
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