A man in his 70s who had "incomplete" skin cancer removed from his left cheek was never given a follow up appointment and assumed he was in the clear.
Five years later his growing cancer was discovered when he started experiencing low vision, numbness and discomfort from his jawbone and skull and a drooping eye lid.
Instead of one surgery to ensure all the cancer had been removed, which could have been done five years prior, he had six weeks of radiation and suffered in pain.
Today, Health and Disability Commissioner Anthony Hill has found the GP and medical centre, who have not been named for privacy reasons, in breach of the Code of Health and Disability Services Consumers' Rights for not communicating the man's skin cancer results to him or arranging follow up.
It comes eight years after the error was made.
In June 2012, the man visited his GP who removed a suspected skin cancer from his left cheek and sent it for testing.
The HDC report said the test report confirmed cancer and recommended further excision to make sure all the cancer had been fully removed.
Although the GP saw the results, he did not communicate the results to the man, or arrange necessary follow up.
The man returned to the medical centre several times over the next five years, but the incomplete removal of the skin cancer was not raised again. Eventually, the cancer returned on the man's left cheek.
In September 2017, the man saw his same doctor and told him that he had a two-month history of increasing drooping of his left eyelid, which was interfering with his vision.
"The man also reported a dull discomfort and relative numbness in his left preauricular region, and some discomfort over the left joint connecting his jawbone to his skull," the report said.
The GP referred the man to the public hospital for investigation and the error was discovered.
In January 2018, the man was seen in the oncology department at the public hospital, and subsequently underwent six weeks of radiotherapy.
Hill was critical of the GP's mistake saying:"The man was deprived of the opportunity to make decisions about his care until the disease had reached an advanced stage."
"By not arranging the follow-up care that the man required, the opportunity to provide timely treatment for the [basal cell carcinoma] was missed, and the disease advanced unchecked for a period of more than five years," Hill said.
The doctor told HDC that he regretted that the man was not referred for further excision.
"[The doctor] does not recall why [the man] was not informed of the result or asked to return for a follow-up consultation," the report said.
"[The doctor] considers it possible that accidentally he filed the email containing the histology result before he had actioned it. "
Hill also made critical comments about the medical centre for not having robust policies for the management of test results.
The commissioner recommended that the medical centre audit 30 minor surgeries to determine whether the results were communicated to the patients in a timely manner and whether follow-up management was appropriate.
He also suggested further training to its staff on the management of test results and consider a number of improvements to its policy for the management of investigation results.
Hill recommended that the GP and the medical centre apologise to the man.
The doctor told HDC that he was very sorry for what happened to the man, and for the significant impact that his omission has had on him. He said that he has always sought to provide the highest standard of care to his patients, and deeply regrets that he did not meet the standard that he strives towards.
In the report, the doctor stated that since this matter was brought to his attention, he has "spent a considerable amount of time reflecting on [his] care and management", and has "no hesitation in apologising unreservedly to [Mr A] for [the] failure to notify him of the abnormal histology in July 2012".
The report said since these events, the medical centre has instituted a new process to minimise a recurrence of a similar situation.
"Specifically, the results management system now generates a "staff task" that must be completed by the doctor when histology is requested. This step helps to prevent an abnormal result being actioned inappropriately."
The GP has also made changes to his own practice as a result of this incident, the report said.
"He no longer leaves results in the electronic inbox, and instead generates a "staff task" in the results management system for the action he intends to take, which will remind him of the task that needs to be completed."
The GP said that he was now more inclined to write result letters to patients, or to send text messages regarding significantly negative results. He also no longer excises tumours from the face.
Separate case: Woman diagnosed with cervical cancer after doing everything right
A woman in her 60s who had two negative smear tests and was not referred for the recommended third was diagnosed with cervical cancer.
Health and Disability Commissioner Anthony Hill today released a report finding the Ministry of Health's National Screening Unit (NSU) in breach of the Code of Health and Disability Services Consumers' Rights for not following its recommendations.
Under NSU guidelines, the woman needed two repeat smears 12 months and 24 months after the negative result.
The woman had a repeat smear 12 months later and the result was negative. However, instead of scheduling the second repeat smear for the following year, as its guidelines recommended, the NCSP scheduled the woman for a smear three years later.
But before she was due for her next screening, she discovered she had cancer.
Since the incident, NSU has implemented a new failsafe workaround mechanism to align the NCSP system with the guideline, and it has initiated a clinical audit for the previous five years.