A Wellington health board has been faulted for inadvertently delaying treatment of a 68-year-old woman with kidney cancer, who later died.
Health and Disability Commissioner Anthony Hill, in a report made public this afternoon, says the Capital and Coast District Health Board breached the code of patients' rights. It did not provide health services with reasonable care and skill, by failing to perform surgery within a clinically appropriate timeframe and because its staff failed adequately to discuss or consider the woman's chest CT scan report.
A senior urology registrar told the woman's GP that she had booked the woman on the urgent list for surgery to remove her kidney.
The woman's surgery was incorrectly entered into the booking system as semi-urgent. It took 78 days from the consultation with the registrar and surgical referral before the operation was done in November 2012.
Three days before the operation, the urology team reviewed an earlier CT chest scan, but did not order another to be done.
In the operation not all of the cancer could be removed and a CT scan showed evidence of disease progression and masses in the middle section of her chest cavity. She later had radiotherapy and chemotherapy but she died.
Mr Hill says it was unsatisfactory that the woman and her daughter-in-law were left with the impression at the meeting with the registrar in August 2012 that the woman would be fine following surgery.
The commissioner's office says he recommended the DHB report to him about changes made since the complaint, including:
• A new surgical booking form,
• A tracking and audit system,
• The appointment of a nurse coordinator in the urology department, and
• The progress of its recruitment strategy to appoint another urology consultant.
DHB chief medical officer Dr Geoff Robinson issued a statement tonight about the findings.
"On behalf of the DHB I want to pass on my condolences to the family and apologise for the delays in the care we provided," he said.
"We accept the HDC's findings and have made changes to our services to ensure the situation that led to the delayed surgery in 2012 does not occur again."
Dr Robinson said advance care planning discussions between patients, their families and clinicians is a priority for the DHB.
"We continually promote the importance of advance care planning to our staff and provide them with resources and skills."