Te Whatu Ora - Waitaha Canterbury has been found in breach of the Code of Health and Disability Services Consumers’ Rights after failing to provide a reasonable standard of care for a woman who was left with debilitating symptoms for nine years before being diagnosed multiple sclerosis (MS).
The woman had been referred by her GP to the public hospital’s ophthalmology service in 2010 following sudden and unexplained vision loss.
She was diagnosed with demyelinating optic neuritis, an acute inflammation of the optic nerve, often associated with MS.
An MRI confirmed the optic neuritis, as well several areas of “abnormal white matter lesions in the brain, raising the possibility of primary demyelination”, according to a report released today by the Health and Disability Commission.
She was referred to the neurology service for further assessment in 2011 and was prioritised as ‘semi-urgent’.
However, the referral was declined due to a limitation on resources, and the woman was not seen by the service. The woman was advised to remain under the care of her GP.
The woman presented to a GP at a new medical clinic in 2015 after experiencing tingling in her left arm and leg, causing her to fall on multiple occasions.
The GP ordered screening tests to investigate a provisional diagnosis of a mini-stroke or an inflammatory disorder but did not refer her for specialist assessment by a neurologist.
They also failed to put in place a management plan for follow-up advice or a structured review of the test results.
She presented to the medical centre again in 2018, where she was seen by a different GP who believed she had a migraine and inner-ear disorder causing vertigo.
The woman called the medical centre several days later due to ongoing symptoms, but the clinical records did not indicate whether the nurse who took the call discussed her concerns with the GP, or what actions were taken to follow up with the woman.
She was “referred urgently” to the neurology services by the medical centre after a third GP found clinical documentation from 2011 noting that the woman’s MRI had shown features consistent with demyelination.
The woman was diagnosed with MS several weeks later.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell said the delayed diagnosis “resulted in missed opportunities for the woman to obtain earlier treatment for her condition”.
"I acknowledge the extraordinary circumstances that faced Waitaha Canterbury following the earthquake in 2011 and the resulting resource constraints, but I do not consider it was reasonable for the woman’s neurology referral to have been declined without any further advice being offered,” Caldwell said in her report.
"I consider the service failure was a contributing factor to the delay in the woman receiving the neurological review and treatment she required.”
Caldwell also found a breach of the Code by the GP who saw the woman in 2015.
"The care provided by the GP did not meet the required standard due to the lack of a referral for specialist assessment by a neurologist, and the lack of a follow-up action plan," she said.
While Dr Caldwell did not find the medical centre in breach of the Code, she made adverse comment about the nurse’s lack of documentation about telephone discussions and follow-up actions with the woman.
Waitaha Canterbury has since made changes to its processes, systems and procedures following the case.
Its neurology service has since also activated an e-triage system, and immediate management advice and strategies are offered to the referrer for possible implementation prior to the neurology clinic appointment.
It is now also normal process for departments to respond to both internal and external referrals, and WC has employed a full-time clinical nurse specialist and a half-time registered nurse specifically for MS outpatient work.
Caldwell recommended Waitaha Canterbury provide a formal written apology to the woman, as well as using the report for staff learning.
The GP seen by the woman in 2015 has since retired from practice, but Caldwell recommended he provide a formal written apology to the woman. The nurse was also recommended to undertake training on documentation.
SHARE ME