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DHB system fails in cancer patient’s care




Failures by both the Wairarapa and Hutt Valley District Health Boards that delayed a woman’s breast cancer diagnosis have been found to be in breach of the Code of Health.

Health and Disability commissioner Morag McDowell released a report yesterday which found the DHBs’ failures were in breach of the Code of Health and Disability Services Consumers’ Rights.

In 2018, a woman in her 40s developed a painful lump in her breast, which her doctors considered likely to be breast cancer. Her local DHB, Wairarapa, did not have a permanent breast specialist surgeon, so she was referred to Hutt Valley for breast imaging and interventional procedures.

The imaging indicated a suspicion of cancer, but a biopsy came back negative. Based on the biopsy result, the Hutt Valley multidisciplinary team diagnosed her with plasma cell mastitis.

Two months after the initial presentation, the woman’s condition deteriorated, and a further biopsy was undertaken, which showed inflammatory breast cancer. The cancer was aggressive, and the woman died in 2019.

McDowell was critical of Hutt Valley DHB’s plasma cell mastitis diagnosis. The DHB did not question the biopsy result when it did not accord with the imaging results, and further imaging and biopsy were not recommended.

She found that the lack of a single clinician in charge of the woman’s care contributed to the false identification.

“Due to multiple clinicians involved, the woman’s care was affected by the lack of clarity as to which DHB and clinician had overall responsibility for her.

“Under the Code, consumers have the right to cooperation among providers to ensure quality and continuity of services, and therefore I have found that both DHBs are equally responsible for the delay in her diagnosis.”

McDowell said the lack of clinical alert after the correct diagnosis was a critical error, and Wairarapa DHB should have had a system to “red flag” abnormal results to clinicians.

“Wairarapa 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.

“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.”

McDowell recommended that Wairarapa and Hutt Valley DHBs provide an update on the changes made in response to these events and report on any further changes implemented. She also recommended that the DHBs provide a written apology to the woman’s husband.

Both DHBs had since made changes to their processes.

To strengthen care continuity, Wairarapa DHB had created a new role to maintain visibility of care for general surgery patients across the region.

The DHB had incorporated a red flag system for abnormal results into an upgrade of its patient records system.

Hutt Valley DHB was developing more comprehensive protocols and policies to improve its services and align discussions with Wairarapa DHB regarding breast patient transfer and management.

McDowell said it was encouraging the DHBs had acknowledged the lack of clarity in its breast service and had implemented changes and several initiatives to improve it.

Wairarapa DHB chief medical officer Mark Beehre said the DHB was committed to implementing the Health and Disability commissioner’s recommendations.

“Wairarapa DHB totally accepts the Health and Disability Commissioner’s finding that we breached the Code of Health and Disability Services Consumers’ Rights.

“We would like to take this opportunity to express our condolences and sincere apologies to the patient’s whānau.”

Beehre said the DHB had written to the patient’s family.

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