The Wairarapa DHB has been slammed in a report that outlines a mistake where they missed a patient's rectal cancer for eight months.
A "weak IT system" is to blame after a 72-year-old man's cancer went unnoticed by staff for months.
The man first went to an unnamed hospital on March 15, 2016, after falling 3m and injuring his right hip and the left side of his chest.
The man was given a CT scan of his chest, abdomen and pelvis before being admitted to the surgical ward.
A radiologist reviewed the images from the scan and noted prominent lymph nodes around the rectum and issued a "sticky note" in the Picture Archiving and Communication System (PACS) used at the DHB.
Around 20 minutes later another radiologist was working through the list of acute causes and typed into a sticky note on the man's file that did not mention the rectal nodes.
When the notes were first created, the second would have been on top and the first would not have been seen when assessing the patient's records.
Several days later the man was discharged from the hospital and the final CT scan and notes about the lymph nodes were not spotted until eight months later.
It was at this stage the man was diagnosed with Stage 111a squamous cell carcinoma of the anus and underwent chemo-radiotherapy treatment and surgery.
Health and Disability Commissioner Anthony Hill looked into the incident and found the DHB in breach of the Code of Health and Disability Services Consumers' Rights.
Hill said the DHB breached the code for failing to provide the man with reasonable care and partially blamed the IT system.
"At the time of these events, the system at the hospital did not allow for electronic sign off of test results.
"[The] system did not allow for electronic sign-off and did not have a clear, effective, and formalised system in place," he said.
Hill suggested the DHB provide a written apology to the man and to provide updates on the progress and effectiveness of its system update.