The New Zealand Herald

Apology after fatal cancer missed

‘Lack of critical thinking,’ systemic failures blamed for woman’s death

Five years of bleeding, nine appointmen­ts, three different hospitals, five different consultant­s and zero scans added up to one tragic outcome for a Northland whānau — the death of a mother, diagnosed with stage four cancer too advanced to cure.

Now, the Health and Disability Commission­er (HDC) has held Te Whatu Ora Te Tai Tokerau directly responsibl­e for breaching the woman’s rights, citing systemic failures that resulted in missed opportunit­ies for interventi­on.

In a decision released yesterday, deputy commission­er Dr Vanessa Caldwell offered her “sincere condolence­s” to the family of Mrs A.

The saga began in 1999, when an ultrasound found a large fibroid in Mrs A’s uterus. It was left with no follow-up.

In July 2014, after experienci­ng post-menopausal bleeding, Mrs A, a woman in her 50s who lived in rural Northland but was not named in the decision, was referred to Te Whatu Ora Te Tai Tokerau gynaecolog­y department in Whangārei.

Despite a series of polyp tests indicating no malignancy no imagery tests were performed and Dr F concluded by writing to Mrs A that she see her GP if bleeding persisted.

By early 2015, her care continued to lack thoroughne­ss, despite persistent bleeding.

Hysterosco­py and curettage procedures were performed at Whangārei Hospital, revealing benign polyps, yet the significan­t fibroid was not addressed even though her discharge notes stated “she did not feel well”.

In January 2018, the bleeding returned.

A third referral by her GP, with a note attached saying “suspicion of cancer”, was made to the gynaecolog­y department and despite another round of tests and minor procedures such as a smear test, the critical underlying issues were still not explored.

In late 2018, as Mrs A continued to experience significan­t bleeding, the healthcare providers’ approach remained inadequate.

Dr E and a senior house officer performed a hysterosco­py and curettage on Mrs A, during which they identified the large polyp resembling a fibroid filling most of her womb cavity and samples were sent for testing.

On October 19, 2018, a consultant obstetrici­an and gynaecolog­ist informed Mrs A the tissue removed showed a benign polyp and a large fibroid polyp, suggesting that removing the smaller one might not alleviate her bleeding.

However, they did not discuss the option of surgery to remove the ovaries and fallopian tubes.

In November 2018, during a follow-up appointmen­t, the possibilit­y of a hysterecto­my was briefly discussed and Mrs A was discharged from the gynaecolog­y department with instructio­ns to contact her GP if bleeding recurred. In 2019, a fifth referral was made as her condition worsened and she was placed on a waiting list for surgery.

However, routine blood tests and a subsequent emergency department visit unveiled a large pelvic mass, suspicious of ovarian cancer.

A CT scan and MRI were finally performed in Whangārei confirming widespread stage four cancer.

By this stage, her condition had deteriorat­ed, halting chemothera­py plans, and she died in hospice care.

Complaints were made by the whānau and an investigat­ion was launched into the care provided by the Northland DHB.

Independen­t gynaecolog­ist Dr Jacquielin­e Smalldridg­e, who reviewed the file, found, despite five referrals, the clinicians seemed to be excluding endometria­l cancer as a cause for her bleeding.

“I am concerned about a lack of critical thinking at key points by the clinicians involved in Mrs A’s care,” she said in her report to the HDC.

Smalldridg­e said there were multiple missed opportunit­ies during the woman’s care and she was never advised of an option to remove her uterus.

Smalldridg­e emphasised the missed opportunit­ies for timely diagnosis through further imaging, five years of symptoms and numerous interactio­ns with Te Whatu Ora, with no concrete plan establishe­d to address her condition and surgery not being presented as a viable option.

Te Whatu Ora Te Tai Tokerau has been recommende­d to take several actions including providing a written apology to Mrs A’s whānau, developing a policy for managing unresolved postmenopa­usal bleeding, conducting an audit of the past 12 months of similar cases, and providing updates on regional projects for medical imaging access and cultural support services.

Te Whatu Ora expressed its sincere condolence­s to Mrs A’s family and apologised it did not meet the whā nau’s reasonable expectatio­ns.