The girl’s son complained to the Well being and Incapacity Commissioner (HDC) who discovered that Well being NZ’s system was “poor” because it did not proceed the surveillance scans.
The girl had been recognized as having a excessive threat of creating liver most cancers after she was recognized with a liver situation in 2011.
A gastroenterologist had met with the girl and, in 2017, six-monthly surveillance liver ultrasound scans had been requested, together with follow-up gastroenterology appointments afterwards.
In 2018, the gastroenterologist referred her for an MRI (magnetic resonance imaging) scan of her liver as her most up-to-date surveillance ultrasound had raised considerations. Whereas no mass had been discovered, an extra MRI in 12 months was urged.
Nevertheless, the girl’s surveillance scans stopped in 2019.
A brand new radiology referral system was put in place which didn’t settle for repeated or recurring requests – together with follow-up liver surveillance ultrasound scans.
Future scans required a brand new referral for every scan.
HDC Deputy Commissioner Dr Vanessa Caldwell stated there have been an absence of “acceptable safety-nets” in place to choose up sufferers already within the system for pre-scheduled appointments.
“A system change requires a certain quantity of forethought in regards to the dangers posed and easy methods to mitigate them.
“When it was decided that surveillance ultrasound scans would require a brand new referral, there seems to have been no consideration as to how this may pose a threat to sufferers requiring new referrals for repeat scans to be generated, and easy methods to mitigate this.”
The girl had been referred to the ED by her GP in late 2022, as she’d been experiencing nausea, fatigue, lowered urge for food and again ache.
A CT scan discovered she had superior liver most cancers and she or he acquired palliative care till she died.
She’d attended hospital for different causes between 2019 and 2022, however there had been no concern about her liver throughout that point, and different specialists she’d seen hadn’t thought of whether or not she was due for a liver follow-up.
Well being NZ’s purpose for the referral methods change, as cited by the HDC report, was “surveillance referrals could cause there to be an assumption that there was no change within the affected person’s presentation between scans, or radiology doesn’t obtain acceptable updates a few affected person’s present standing, which comes with a medical threat.”
There have been additionally impacts on scheduling, as repeat appointments usually weren’t cancelled in instances the place a affected person’s circumstances had modified.
The HDC report discovered that whereas the explanations for a system change is perhaps legitimate, there hadn’t been checks to find out that these already on surveillance schedules weren’t missed.
“Within the context of a stretched useful resource in gastroenterology, I contemplate that it was not the only real duty of the referrer (on this case, the gastroenterologist) to make new referrals for all sufferers underneath surveillance,” Caldwell stated.
She stated there ought to have been a message despatched to GPs in regards to the change, too.
Well being NZ had urged to the HDC in its response to the investigation that the girl’s GP had failed to choose up on the truth that the surveillance scans weren’t being carried out, and this had led to the delay in her prognosis.
“There isn’t a proof that the GP was requested to undertake a monitoring position on this state of affairs. Additional, there is no such thing as a proof that the GP was made conscious of the system change.”
The HDC was crucial of the communication by Well being NZ to workers, as an electronic mail despatched hadn’t been adequate to elucidate whose duty it was to make new referrals.
An extra failing by Well being NZ on this girl’s case had been the missed follow-up outpatient appointment with the gastroenterologist – it was not booked attributable to a course of error within the Outpatients Appointment Workplace.
Had that been booked, the specialist may need picked up that the girl wasn’t getting her common surveillance scans; the additional really useful MRI follow-up may even have been booked.
The HDC report stated that whereas “finally earlier detection might not have resulted in a special final result for [the woman] it could possible have allowed her time to just accept the prognosis and spend extra time as she would have needed.”
For the reason that HDC investigation, Well being NZ Te Whatu Ora has indicated it’ll improve communication to GPs relating to liver ultrasound scans, full an audit of the liver cirrhosis surveillance programme to make sure that no different surveillance sufferers have been missed.
It could additionally apologise to the girl’s household for the delay in her most cancers prognosis.
Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She beforehand lined court docket and native authorities for the Nelson Mail, and earlier than that was a radio reporter at Newstalk ZB.
