A doctor who forgot to tell a woman who later died that the bone erosion in her painful shoulder was probably cancer was guilty of "appalling negligence", a breast cancer lobby group says.
"We would advise women to request copies of all medical and specialist reports including x-rays so they can read and discuss them with their doctor," said Breast Cancer Aotearoa Coalition chairwoman Libby Burgess.
The unnamed GP has admitted failing to act on a radiologist's suspicion that cancer had spread to the woman's arm. He has been referred to the Health and Disability Commissioner's director of proceedings for possible charges before the Health Practitioners Disciplinary Tribunal.
Ms Burgess urged women to read their medical files and use them "to help them make the best decisions".
"This woman has fallen through the cracks. We feel for the family who have lost a loved one in such appalling negligence.
This case serves as a timely warning to all GPs and medical professionals to properly follow up all patient reports."
The case also showed that women who had had breast cancer must stay vigilant much later for signs of it having spread.
The woman, 57, was referred by her GP in November 2009 to a radiologist for an x-ray and ultrasound scan because of pain in her left shoulder after a sporting injury months earlier, according to commissioner Anthony Hill's report, published this week.
The radiologist reported tendon damage and that the "moth-eaten" changes and bone erosion in her upper arm were "highly suggestive" of cancer that had spread from elsewhere in the body.
The woman had had a partial mastectomy in 2003.
The GP made a note in his medical centre's computer system about the tendon tear and the possible recurrence of cancer, and recalled the woman for a consultation. However, when he saw her - on the same day - he gave her a steroid injection and helped her to claim accident compensation, but omitted to mention the possible cancer finding.
He told the commissioner he "either overlooked or completely forgot" the radiologist's cancer comment.
In January 2010 the woman returned because of the disabling pain. The GP referred her to an orthopaedic surgeon, again omitting the radiologist's cancer comment.
The surgeon, after a new x-ray, diagnosed cancer. The woman received chemotherapy and radiotherapy but died this year.
The commissioner's medical adviser, Dr David Maplesden, said the GP's oversight caused a three-month delay in the woman's diagnosis.