A specialist has been faulted over the case of a woman who died at 39 of cervical cancer.
The woman suffered recurrent episodes of bleeding after having sex, which she reported to her GP in April 2007, two months after the birth of her second child.
The case was reported yesterday on the Health and Disability Commissioner's website, in a decision by former commissioner Ron Paterson. No parties were named.
The GP, Dr C, decided not to take a cervical smear test, instead ordering an x-ray and an ultrasound scan to rule out the possibility of a retained swab from the caesarean birth - an approach ruled appropriate by a medical adviser to Mr Paterson.
The patient saw Dr D the following month. She took a vaginal bacterial test, prescribed antibiotics and, owing to a vaginal discharge, deferred taking a smear, which was likewise ruled appropriate. The bacterial test was clear and the ultrasound found no sign of a swab and in late May 2007, Dr C referred the woman to a hospital gynaecologist, Dr B.
Dr B did not take a smear, nor do a colposcopy - a visual inspection with a magnifying instrument. He told the woman that her condition was related to breast-feeding and reassured her that she needed no further treatment.
In October 2007, the medical centre declined the woman's request for a smear, because she was not due for one for several months.
In February 2008, she was still suffering post-coital bleeding.
Dr D took a cervical smear. It was abnormal and Mrs A was subsequently diagnosed with cervical cancer. She died last year.
Mr Paterson said he was left in "significant doubt whether Dr B's management was reasonable", but he concluded he had not breached the code of patients' rights by choosing not to perform a smear or colposcopy.
However, he did breach it by failing to give specific follow-up advice to the patient and Dr C.
"Dr B omitted to advise the referring GP of the need for further evaluation if Mrs A's symptoms persisted."
Nor did he document any advice to Mrs A about when next to see her GP if the symptoms persisted, Mr Paterson said. The gynaecologist had told the commissioner's office he was "sure" he had done this, which was his standard advice to patients, although Mrs A did not recall this and her actions were consistent with no longer being worried about the bleeding.
"I note that my experts qualified their advice, about the reasonableness of Dr B not performing a smear, by stating that Mrs A needed to be told to return to her GP if her symptoms persisted."
Mr Paterson recommended Dr B apologise to the woman's family and that all three doctors review their practice in light of the report.