A 46-year-old woman was not told of results which found she had a tumour that eventually killed her for four years due to a failure in the Waikato DHB's referral systems.
In a decision released by the Health and Disability Commissioner today, the HDC has ordered the Waikato District Health Board to apologise to the woman's family after the health system repeatedly let her down and resulted in a "pattern of seriously suboptimal care".
Several doctors also failed to make her aware of the prognosis during four years of visits to the hospital, delaying access to the correct treatment.
The woman had her appendix removed in 2009 and a histology from the appendix showed she had a tumour. The report was seen by a junior doctor but was not referred do the locum general surgeon, the patient or her GP.
Three years later the woman, who was still unaware about the tumour, returned to see a general surgeon complaining of a lower abdominal pain, but the earlier histology report was still not picked up.
The woman was referred to an obstetrics and gynaecology registrar and told it could be endometriosis.
As the woman continued to get sicker and could not eat and kept losing weight, the report where the tumour was discovered was reviewed in 2013 and for the first time it was recognised that nothing had been done about it.
However, it was still not escalated and the woman remained oblivious.
Eventually a laparoscopy and peritoneal biopsy found the woman had secondary cancer and she was told of both findings, but by now she was too sick to tolerate surgery and was referred to palliative care and died.
The HDC has criticised the Waikato DHB saying it held primary responsibility for the pattern of errors in the case and raised concerns about the systems in place during that time that did not see the abnormal results acted on.
The HDC also criticised the way missed results were identified promptly, errors were disclosed soon enough and criticised the hospital for not being able to identify who the junior doctor was who saw the results identifying the tumour but did nothing about it.
A raft of recommendations were made to the DHB included performing a randomised audit of patient rectors, using the HDC report as a basis for staff training and apologising to the women's family for the failings identified in the report.
In a statement, Waikato Hospital executive director Brett Paradine said he had sent a letter of apology to the family via the commissioner and that a number of changes had already been made to how it reviewed and responded to clinical results.
He blamed systematic errors in acknowledging results for contributing to the late diagnosis of her condition.
"However, we never lose sight of the fact that improvements to our systems and processes have come about through a tragic experience for her family. I am committed to making sure the lessons we have learned are embedded in our organisation," he said.
The Waikato DHB will report back to the HDC on the outcomes of its recommendations in six months.