In May 2023, at a follow-up appointment for a neck melanoma that had been excised in February 2021, she raised her gastrointestinal symptoms and unintentional weight loss issues with an ear, nose and throat registrar.
She told the registrar she had a node on her neck, and they arranged for a cell sample to be taken.
Further investigation led to a bowel cancer diagnosis.
Now, the HDC has recommended a doctor involved in her earlier treatment apologise to her family.
Ongoing stomach pains
The woman met the doctor in late 2021 when she complained of longstanding gastrointestinal symptoms of abdominal pain, bloating, vomiting and loose stools. She said the symptoms were worse than before.
It was noted she was barely able to eat and had lost 6kg in four weeks.
The doctor noted she was tearful and felt she had been “fobbed off” and wanted answers.
The doctor arranged for blood and stool testing and an abdominal ultrasound and started her on trial medication.
He texted her in early 2022 to say her that her blood and stool tests had come back normal and asked whether she had felt any benefit from the medication.
She said it had worked well, her cramps had improved, but that she was still experiencing constant diarrhoea.
In March 2022 she had a phone consultation with the doctor and reported that the medication was working well.
He advised her of an incidental finding from her abdominal ultrasound.
She had no further consultations with any doctors until after she was diagnosed with cancer.
Missed opportunities
The HDC sought advice from GP Dr Fiona Whitworth, who said a weight loss of 6kg in four weeks should have been a red flag.
It would be common practice to have referred the patient urgently to gastroenterology for a review and a colonoscopy, even if the results of the ultrasound and bloods ordered by the doctor were normal.
Whitworth said the text messages in early 2022 presented another opportunity for a referral and potential diagnosis, or at least a further in-person consultation.
Further, Whitworth advised that the phone consultation was another opportunity where a referral could have been made.
The woman experienced abdominal pain, bloating, vomiting and loose stools. Photo / 123RF
The doctor told the HDC he felt the woman’s weight loss could have been explained by her restrictive dietary practices and/or by her difficulties keeping food down.
He had planned to follow up once they had the results of the investigations he had ordered, with an option for a secondary care referral.
He said no secondary care referral was made as ultimately, irritable bowel syndrome symptoms were longstanding, her blood tests and scans were reassuring, and she was responding to medication.
Further, having reviewed the local criteria for colonoscopy on the secure health pathways website, he did not believe she fulfilled the criteria for colonoscopy.
Whitworth acknowledged significant obscuring factors, such as the frequent combination of irritable bowel syndrome with other conditions and the possibility of weight loss from narrow dietary intake.
She also noted that several GPs were involved in the woman’s care over this time frame, and that there were limitations on face-to-face contact because of Covid-19.
Whitworth acknowledged the doctor ordered the correct range of tests and investigations, the results of which were mainly normal, which may have led to some degree of false reassurance.
The doctor provided evidence to HDC that since receiving the complaint, he had completed learning modules on colorectal cancer and early diagnosis of cancer in young adults via the Royal College of General Practitioners.
Doctor breached the code of rights
Deputy Health and Disability Commissioner Dr Vanessa Caldwell said in a decision released today that the doctor had breached the code of rights:
in that no examination was undertaken or weight documented at the appointment in December 2021.and that the woman was not referred to gastroenterology, nor referred or reviewed in person in January 2022.
“I acknowledge that there were mitigating circumstances that made this a complex presentation.
“However, in my view, these do not sufficiently outweigh the fact that a referral was indicated from December 2021, and that there were three separate missed opportunities for a referral and potential diagnosis between December 2021 and March 2022.
“While I accept that a referral was indicated, I note that it is not possible to determine whether an earlier referral would have changed the outcome; with hindsight, it is understandable to question whether the course of her health would have changed had she been referred for specialist review at an earlier stage.”
She noted the doctor had returned to live and work overseas and had proactively undertaken further education on colorectal cancer and early diagnosis of cancer in young adults.
She recommended that the doctor provide a written apology to the woman’s family and that it be sent to the HDC within three weeks of the date of the report, for forwarding to her family.
A copy of the sections of the report that related to the doctor would be sent to the Medical Council of New Zealand.
Al Williams is an Open Justice reporter for the NZ Herald, based in Christchurch. He has worked in daily and community titles in NZ and overseas for the last 16 years. Most recently he was editor of the Hauraki-Coromandel Post, based in Whangamatā. He was previously deputy editor of the Cook Islands News.