Hospital falls down on smear test results

Jenny Westgate

Women needing follow-up care for abnormal cervical smear results were inadvertently ignored by their public hospital, and one woman's invasive cancer went undetected and untreated for too long, a report reveals.

An inquiry by Health and Disability Commissioner Ron Paterson, sparked by a complaint from the cancer patient's husband, found that the Waitemata District Health Board and two of its gynaecologists - both unnamed - breached the patient's rights. She had been subjected to "totally unsatisfactory" delays.

The investigation into the case of "Mrs A" brought to light lapses in the care of 28 other women, some of whom had high-grade abnormalities of the cervix but were not given follow-up appointments.

A systems error has been blamed, and the hospital says the problems are now resolved.

In his report, released today, Mr Paterson said women in New Zealand were entitled to "a far better standard of care and communication from the publicly funded health system".

"It is unacceptable that a disease that is so well known, well described and for which there are clear, established guidelines for diagnosis and treatment had gone undetected and untreated for so long in a public hospital setting in 2002/03."

He recommended that the health board, which accepted his findings and apologised to Mrs A, review its gynaecology service. When it did that, it brought to light other cases.

The board's clinical director of gynaecology, Associate Professor Jenny Westgate, said the review showed that seven women with high-grade abnormalities of the cervix had had inadequate follow-up after initial colposcopy assessment.

A further 21, with a mixture of abnormalities, had been seen and treated as necessary, but their follow-up had not been completed within the appropriate time.

In some cases, including five of the high-grade cases, the hospital had not made the necessary appointments for the women.

The others had failed to turn up for an appointment that had been made.

All of the women had now been contacted, Professor Westgate said.

"To our knowledge none of the high-grade ones have developed cancer. The other people ... they didn't have cancer and we expect to be able to finish their follow-up."

The failure to make appointments was a systems error, she said. It would be too difficult to explain what happened in each case, but she was confident that a new auditing process would prevent a repeat.

Professor Westgate said the colposcopy delays that led to the complaint no longer occurred.

Mr Paterson said comments in 2002 by hospital staff to Mrs A, who had been married for 21 years, about unsafe or unfaithful sex causing her condition were "totally inappropriate" and could have "reduced her willingness" to attend the hospital.

His adviser had reported that this could be because of "communication problems with overseas-trained doctors". Mr Paterson noted Waitemata's comments to him about a lack of resources and other factors contributing to the woman's care.

But he said there were repeated missed opportunities for the hospital to take a cervical smear, "and a notable failure to fast-track treatment once the ulcerated cervix was identified".

"The awareness and response to cervical cancer on the part of medical staff appears to have been poor."

Dr Sue Belgrave, a gynaecologist at North Shore Hospital, told the Herald last night that Mrs A's case was well known and regrettable.

"Certainly [in this case] there were process delays that ideally shouldn't have happened and that's regrettable.

"It also happened near Christmas time, a problem all health services have to deal with, which can compound a situation."

She said steps had been taken and it would be "highly unlikely" that a similar situation would happen again.

Dr Bernard Brenner, who has been a practising gynaecologist on the North Shore for 25 years, said a three-week wait for treatment in the public health system was not unusual.

He said only patients in emergency circumstances, such as if they were haemorrhaging or in acute pain, usually got immediate treatment.

It is five years since the Gisborne ministerial inquiry identified major failings in the national cervical screening programme.

The programme's clinical leader, Dr Hazel Lewis, said the Waitemata board's review and changes were appropriate.

She was unaware of other boards having similar problems.


CASE STUDY
Cancer goes undetected and untreated

Mrs A, who was in her 40s, complained in October 2003 after delays in her diagnosis at North Shore Hospital. She was first admitted in April 2002 for abdominal pain but a smear was only taken months later.

She was readmitted to the hospital on November 28 with pain and her cervix was found to be ulcerated and a scan showed a "cervical mass".

However, more than three weeks elapsed between her "urgent" referral to the hospital's colposcopy clinic and the date of the visit.

Under national guidelines she should have been seen within a week, but the board admits that because of pressures on the colposcopy service in 2002, even urgent cases were not always seen that quickly.

At the clinic, a doctor who was not identified by name, noted that Mrs A's cervix had become a malignant tumour that bled to the touch, but told her only that "things are not looking good", not that it was cancer.

The doctor wanted laboratory proof first, which came on January 3, ahead of another visit on January 20.

Mrs A's cancer was treated at another hospital and her husband told the commissioner last October that it was in remission.