Wellington hospital failures led to cancer patient's liver transplant - Commissioner
Capital & Coast district health board has been ordered to formally apologise to a woman with cancer for failures in its care which meant she had to have an urgent liver transplant, the Health and Disability Commissioner Morag McDowell says.
The patient, a Cook Island Māori woman in her 40s, was being treated for lymphoma – cancer of the white blood cells, and had a history of hepatitis B – a serious liver infection.
She was diagnosed in August 2018, and was taking a medication called lamivudine which works by decreasing the amount of hepatitis B in the blood. This was prescribed as cancer treatments suppress the immune system.
In a report, released on Monday, the Commissioner states: “The intention was that the woman would continue taking lamivudine for one year following chemotherapy, but owing to a number of systemic issues at CCDHB, the medication was inadvertently stopped...”
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The patient took her last prescribed lamivudine dose on January 3, 2019. Three and a half months later, she was in the hospital’s emergency department with vomiting and jaundice, and was told her hepatitis B had returned.
She failed to respond to treatment for the liver infection and the on-call clinician told the patient and her whānau she wasn’t eligible for a liver transplant due to her lymphoma. This was on the basis that immunosuppressive drugs used in organ transplants would cause her cancer to spread more rapidly.
But in late April, she was accepted for a transplant and this went ahead in early May, but was complicated by a serious injury to her small bowel and kidney, the Commissioner’s report said.
The woman was given “inadequate” information about the need to continue her hepatitis B medication, McDowell said.
“The information was only verbal, with no written reinforcement in pamphlets, clinic letters, or medication labelling, and no treatment summary was provided to the woman or her GP.
“The DHB lacked clarity about roles and responsibilities, and there was no formal protocol for preventing hepatitis B reactivation in patients undergoing immunosuppressive therapy,” McDowell said.
“There was no clear plan to ensure the woman stayed on lamivudine following chemotherapy. As a consequence, her prescription for lamivudine was stopped too early and this went unnoticed resulting in her hepatitis B being reactivated.”
The Commissioner found the health board in breach of right 4(1) of the health and disability code, which recognises the right that services be provided with reasonable care and skill. She also found the health board breached right 4(5) which states consumers have the right to co-operation among providers.
The report highlights the need for clear roles and responsibilities to make sure all those involved in a patient’s care have a clear clinical picture, McDowell said.
It was also crucial protocols were up-to-date and formalised, and systems had checks and balances in place such as clear plans, medicine alerts, and adequate information provided to the patient and GP, she said.
McDowell also noted one of the complainants raised concerns of institutional racism and the poorer outcomes experienced by Pacific peoples in New Zealand’s health system.
In a response to the Commissioner, the health board stated: “the DHB recognises it has an obligation to do better for Māori and Pacific patients who unquestionably do experience inequitable health outcomes”.
Along with a written apology to the woman, Commissioner McDowell recommended Capital & Coast provide an update on changes that followed this incident, and use an anonymised version of the report as a case study during education sessions.
Capital & Coast’s chief medical officer John Tait admitted the health board had failed the patient.
“Capital & Coast DHB wishes to take this opportunity to apologise once again to the patient and their whānau that this occurred.
“No harm to a patient under our care is acceptable. We take patient safety extremely seriously, and acknowledge that we failed the patient and whānau in this instance.”
Tait said the health board has accepted the Commissioner’s findings and carried out its own review on the case.
“Our review highlighted gaps in coordination of care for people with complex conditions undergoing treatment with the cancer service and across the health network to primary care.”
It had since introduced a protocol on hepatitis B in patients with cancer to define roles and responsibilities, to recommend their case is discussed with the Infectious Diseases team before starting chemotherapy. It had also formalised guidelines for “coordinated care” of people at risk of hepatitis relapses with cancer treatment and created a patient leaflet about hepatitis B risks.
Tait said the health board had implemented an electronic care management system to set up plans for chemotherapy patients who must remain on medication for certain periods, appointed a Māori Health Cancer Nurse coordinator, and improved communication with patients by ensuring all clinic letters from cancer services to GPs are also sent to patients.