A woman in her 60s died after a GP failed to physically examine her during an appointment, leading to a delayed oesophageal cancer diagnosis, the Health and Disability Commissioner (HDC) has found.
The woman attended consultations with two different doctors at the same medical centre in 2020.
She had symptoms including fatigue, weight loss, and eating difficulties, and a history of heavy drinking and high blood pressure.
"The first doctor the woman saw (a part time locum) requested blood tests for a general initial investigation," the HDC said.
A locum worker is temporarily filling in for another doctor who is ill or on leave.
The blood tests came back mostly normal, apart from indicating the woman's thyroxine level was low.
"The doctor said she made a request to the public hospital for an ultrasound scan of the woman's liver."
The hospital's radiology department wrote a letter back, advising the woman was classed as "category C", meaning she would have to wait 30-38 weeks for an ultrasound. The letter asked the doctor to review this categorisation — but it initially went to the wrong place.
"The letter was sent to another practice at which the doctor worked and then it was posted to the correct medical centre. However the doctor does not remember ever seeing it," the HDC said.
The woman then visited the same medical centre again, later that month. She was seen by a different doctor.
By now, her family was "very concerned". Her husband attended the appointment with her and he did most of the talking.
"The second doctor did not perform a physical examination or record any vital signs. He prescribed levothyroxine (for thyroid hormone deficiency) and omeprazole (for indigestion) and planned to review the woman again in four to six weeks' time and repeat blood tests."
The second doctor said he told the woman she should be admitted to hospital that day — but he claimed she refused because it was a public holiday. The woman's husband told the HDC he didn't remember hearing that advice, and it wasn't recorded in the clinical notes.
Five days later, she presented to the hospital's emergency department. She was no longer able to swallow liquids.
At the hospital, she was diagnosed with metastatic oesophageal cancer, and died a few weeks later.
The findings
Aged Care Commissioner Carolyn Cooper found the second doctor breached the Code of Health and Disability Services Consumers' Rights by failing to examine the woman's abdomen. Cooper urged him to apologise to the family.
She also recommended the medical centre's owner "consider the implementation of a new management process for filing of documents and consider implementing a new system for the appropriate management of locums, to ensure continuity of care".
Cooper also criticised the first doctor's documentation as "incomplete", and said the medical centre "lacked policies regarding the management of outstanding results and tasks of short-term locum doctors".
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