A woman who died during cancer surgery after being forgotten about for more than a year in a hospital system could have beaten the disease if the blunder was not made, an inquest has found.
Anita McCall, 48, died in Hutt Hospital in August 2006 as a result of complications during surgery.
She was referred to the hospital by her GP in January 2005, for suspected haemorrhoids, but it was 13 months before she was seen by a specialist. By that stage rectal cancer had started to ravage her body.
Coroner Garry Evans' findings come a week after the health and disability commissioner revealed details of three other patients who suffered serious health complaints after being "lost in the system".
In each of those cases - involving Capital and Coast, MidCentral, Counties Manukau, Auckland and Northland district health boards - patients suffered treatment delays caused by ineffective referral systems or poor communication.
Mrs McCall, a mother of three, thought she had haemorrhoids. She suffered "extreme" pain and "cried herself to sleep" but thought her troubles would be temporary.
"She was gutted by the diagnosis, absolutely gutted," her husband, Tony McCall, told The Dominion Post. "We had no inkling it was cancer and if we did we would have got a second opinion.
"It was a massive shock to us. I had to watch her go through all of this and it shouldn't have happened. She should still be here with me today. The mistake cost my wife her life."
Mr Evans said three letters of referral from Mrs McCall's GP got lost in the Hutt Valley health board's administration system and she "became forgotten".
A report into the incident shows the blunder reduced the chance to control the cancer, affected Mrs McCall's quality of life and contributed to her premature death.
The report by Garry Forgeson says if Mrs McCall had had an initial assessment within the recommended two to four months after referral there was "some possibility of cure".
"There is also a definite probability that the cancer would have been locally manageable."
An internal review by the board blamed its "poor systems" at the time.
Mr Evans said the board had taken all reasonable steps to ensure that what happened in the "very sad" case was unlikely to recur.
"It is unnecessary for the court to say that what happened here should never happen again. The board is well aware what the public wants is a high-quality local hospital that they can access. The evidence before the court shows that the board is striving to ensure this."
Representatives from the board personally apologised to Mr McCall, which he said had helped the family "move on".
"I was extremely upset and it took a lot of guts for them to come to my house and say sorry."
Board chief operating officer Jill Lane had accepted personal responsibility for the incident, but evidence showed fault lay with administrative staff at the hospital's surgical outpatients service.
Ms Lane said that though Mrs McCall's condition was classed as semi-urgent, 95 per cent of all referrals were in this group, and it was impossible to assess patients within the recommended time.
She said that since the mistake a new system that had more categories to class patients had been introduced, which made for better patient management.
A review by the health board showed that the day Mrs McCall was referred to a specialist, 687 patients were waiting to be seen for the first time.
Of these, 248 had been waiting longer than six months and 82 more than a year.
- The Dominion Post
Should fluoride in water be the responsibility of central government?