A breast cancer patient died after a delay of nearly two years in informing her of her positive test results.
In October 2009 a woman had a mastectomy performed by a breast surgeon at a private breast clinic, and following this the surgeon sent the tissue for tests, Health Commissioner Anthony Hill said.
One of the tests was to determine the HER2 receptor status, which if positive indicates a type of cancer that tends to be more fast growing, and may respond to Herceptin, which targets HER2 positive cancer and is given in conjunction with chemotherapy.
In November the woman met with a radiation oncologist to discuss adjuvant therapy options, and at that time her HER2 result was unavailable, Mr Hill said.
The radiation oncologist advised the woman she had a very good prognosis and recommended radiation therapy, not chemotherapy.
A week later the woman's HER2 result was available and neither the breast surgeon nor the radiation oncologist informed her of her positive result, he said.
The woman underwent radiation therapy at a public hospital where she was transferred as a patient, and her HER2 result incorrectly appeared as negative on seven hospital clinic notes.
Nearly two years later the woman developed back pain, and after a bone scan she was diagnosed with metastatic disease at the public hospital.
The hospital medical oncologist then obtained the woman's positive HER2 result, and informed her of it for the first time, Mr Hill said.
The woman later passed away from the metastatic disease.
In his investigation Mr Hill found the radiation oncologist to have failed to provide the woman with all the information she would reasonably expect to receive. He should have also offered a referral to a medical oncologist, Mr Hill said.
Mr Hill said the breast surgeon's care was adequate, but comment was made that he should have checked with the woman that she had received her HER2 result.
Mr Hill also made adverse comment in regards to the private breast clinic's patient management systems and the public hospital's system for managing patient records.