A doctor has been found to have failed a patient who later became a tetraplegic after he forgot to contact the man about his abnormal blood results.
The Health and Disability Commissioner, Anthony Hill, today released a report revealing the details of the case.
A 21-year-old man said to be "generally healthy" had come down with flu-like symptoms and aching bones in May, 2011.
He sought help from the unnamed general practitioner just over a week after feeling ill and a physical examination was carried out. He was given pain relief medication and blood tests were also carried out the same day.
The next morning, the doctor looked at the young man's results, which found a number of abnormalities, including an abnormal blood count, elevated levels of C-reactive protein and abnormal renal function tests.
The report said the GP had intended to get a nurse to contact the man to give him his results and to see how he was progressing.
"But he forgot to ask the nurse to do this," the report said.
The doctor told the Commissioner: "It may have slipped my mind as a result of consulting with other patients that morning after I reviewed the results."
Two days after the results had come in, the young man's father took him to an emergency clinic after the man found he could not walk. Another doctor reviewed the results the GP had ordered and the patient was admitted to the intensive care unit in hospital.
A number of health experts later examined the man, who underwent more tests and scans to try to figure out exactly what was wrong. Those tests found he had swelling of the liver and spleen and swelling of the brain.
The report said: "The man was eventually reviewed by a visiting neurologist from another district health board, who considered that the man's condition was consistent with severe acute demyelinating encephalomyelitis --a post-infectious inflammatory disease that damages the protective myelin layer around the nerve fibres in the brain, following a systematic viral illness of undetermined nature."
The young man underwent more treatment in a different hospital, where he was admitted for three months. He is now a tetraplegic living in a care facility.
The doctor was found to have been in breach of the Code of Health and Disability Services Consumers' Rights for failing to fully inform a man of his abnormal blood test results and failing to ensure that the abnormal results were followed up in a clinically appropriate manner.
Mr Hill acknowledged the fact that the mistake was a human error. But he said doctors owed it to their patients to handle test results properly and ensure that they were contacted of all major outcomes.
The Health and Disability Commissioner recommended that the GP make a formal apology to his former patient.
Deputy chairwoman of the NZ Medical Association and chairwoman of the GP Council, Dr Kate Baddock, acknowledged that doctors worked hard to ensure results were followed up, but that mistakes could happen.
"It's human to err -- but you never want it to be at the expense of a patient's health. I think we all try our very best to ensure that any abnormal result is followed up on."
Dr Baddock said practice systems were "less than perfect" and many practices had a manual system.
"Following up of results is always problematic because we get so many, so the systems that we have in place are probably less than perfect -- and that's partly because the [system] is not able to selectively choose results for us to automatically have to follow up on.
"You have to either select all results or there's a couple that you can choose to basically review if you don't see the results or you don't follow up on it."