A breast cancer survivor who complained of severe back pain was passed between numerous doctors who took months to realise her cancer had returned.
Seven months after her first emergency appointment at North Shore Hospital, doctors finally diagnosed the woman's cancer of the spine.
The woman died in 2011.
In a report released today, Health and Disability Commissioner Anthony Hill found the medical team failed to co-operate, share notes or carry out an MRI or bone scan early on.
The woman's husband slammed the hospital's "tunnel vision approach" to diagnosing his wife, the HDC investigation reported.
"Considering that my wife had two chronic illnesses, why did no-one, apart from the ED doctor, think to check the spine for cancer. What is more disturbing is the impression that they would do the same again."
Waitemata District Health Board has since reviewed its communication policy and apologised to the woman's family.
The woman had a mastectomy in 2002 for invasive breast cancer and suffered chronic pain syndrome of the knees.
She had an 80-per-cent risk of the cancer recurring within the next five years.
In October 2007, she appeared at North Shore Hospital's emergency department after suddenly experiencing severe lower back pain.
An x-ray of her lower spine showed nothing unusual so doctors excluded cancer and discharged her the following day.
She was referred to the general medical team, who, taking into account her medical history, diagnosed a muscle spasm.
Again, she was referred on, this time to an orthopaedic team.
The orthopaedic registrar diagnosed the problem as an acute disc prolapse and prescribed pain relief medication.
However, the pain continued and she only felt comfortable when lying down, the HDC found.
She was then seen by a breast surgeon and oncologist, both of whom did not mention the back pain in the medical notes.
It was not until May 2008 - seven months after her first hospital visit - that she was referred on for an MRI scan.
Doctors diagnosed cancer in the spine and pelvis the following month.
In the HDC finding, Hill said the complainant at one stage even asked for an MRI scan.
The woman had said a male doctor refused her request in a condescending tone and told her to "go home for another 6 months and wait".
However, Hill was unable to find any record of this conversation.
The medical team failed to undertake an MRI or a bone scan in light of the woman's cancer history and poor response to pain relief medication, Hill said.
Waitemata District Health Board chief medical officer Dr Andrew Brant said the health board "acknowledges and accepts" the findings.
"The DHB regrets that it did not do more to investigate the cause of the patient's back pain in 2007, particularly in light of her clinical history, and to communicate effectively between services involved in her care. The DHB has expressed its condolences to the patient's family," he said.
Brant said the health board had reinforced to clinical staff the standard recommendations for managing back pain, the indications for further investigation and MRI scanning, and the need for clear communication and co-ordination between hospital services.
"I want to reassure patients and their families that we are always striving for a high level of consistent quality care, delivered by a team of dedicated and compassionate staff. We endeavour to do our utmost to learn from mistakes and to ensure our hospitals become safer and better places for the communities that we serve," he said.
Brant said in the five years since the incident the health board had made a number of changes. Clinicians now have access to a patient's electronic health records - which they're encouraged to review while assessing care - and are part of the Northern Region Health Plan which enables reliable access to core electronic clinical documents for everyone involved in a patient's care.
- © Fairfax NZ News
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