A Waikato woman in her 80s has been left without a bladder and is in an extremely weak state after alarming signs of her cancer were ignored by two GPs for three years.
An oncologist has said it's likely her cancer could have been picked up three years earlier and that her treatment would have been "relatively simple for a reasonably well patient of her age" if it had.
Today, the Health and Disability Commission have released a damning report finding Tui Medical Centre and two of its GPs in breach of the Code of Health and Disability Services Consumers' Rights for repeated failures of the woman's care.
"The impact of living without my bladder, and the effects of chemotherapy have left me weaker, and unable to live the life I did prior. I was a fit person who looked after the house and garden, and was the full-time carer for my husband who is disabled," the woman said in the report.
She is not being named for privacy reasons.
Between 2014 and 2017, the woman had several consultations at the medical centre about blood in her urine. She was treated with antibiotics, despite her urine tests showing no infection.
The investigation - led by former HDC commissioner Anthony Hill - found the woman was not notified of her results, and no further follow-up action was undertaken by the GP.
The woman was not referred for a specialist review of her symptoms until more than three years after her initial consultation, at which time a cystoscopy revealed tumours in her bladder, the report said.
She had multiple surgeries to remove the tumours, her bladder, uterus, and lymph nodes before getting chemotherapy.
The woman has filed an ACC treatment injury claim and expert advice was sought from an oncologist, who said the cancer likely could have been picked up in 2014 and if it had treatment would have been much simpler, the report said.
The woman has now completed all scheduled treatments and was being monitored for any return of the cancer.
The commissioner was critical of a number of failures including a lack of the appropriate standard of care, not informing the woman of her test results and for the lack of effective co-operation between the GPs who provided care to the woman.
"Clinicians must do the basics — read the notes, ask the questions, and talk with the patient," he said.
"The delay in the woman's diagnosis with bladder cancer had significant consequences for her."
Hill said the medical centre breached the Code by not reviewing her clinical history adequately and not following up her persistent symptoms appropriately, and thereby failing to provide services to the woman with reasonable care and skill.
"With medical practices focusing less on individual doctor consultations and more frequently involving a multidisciplinary team, attention must be paid to the issues that can arise when no single clinician takes overall responsibility for the patient, and the need to ensure continuity of care.
The commissioner recommended:
• The medical centre discuss the findings with all staff employed who were involved in the woman's care.
• Update its policy for the review of test results when staff require leave at short notice.
• The medical centre should review its processes around provision of care to patients who present repeatedly with the same problem.
• Report back to HDC regarding implementation of the changes it has made.
• Provide the woman with a verbal and written apology.
• The GP attend a Medical Protection Society workshop, review the HealthPathways guidance on urinary symptoms.
One of the GP's at the clinic said in the report: "At the end of it all, there is [a woman in her 80s] who was poorly done by and that is not something any of us can live down."
"I would like to take this opportunity again to apologise to her and wish her all the best with her ongoing treatment and recovery."
Tui Medical said in the report as a result of this incident it identified areas for improvement and changes had been made including peer reviews and audits of notes; separating Urgent Care and General Practice to allow better continuity of care; and making sure all staff are well informed of the guidelines on urinary tract infections.
Another HDC report released today found a woman living with Parkinson's suffered panic attacks, blurred vision and vomiting after being given the wrong medication by a pharmacist.
Though the label was correct, the medication was not and she had been taking it for a month before the mistake was discovered.
In the report, the woman said the error had cost her and her family financially, physically, and mentally.
Deputy Commissioner Kevin Allan found there was failure to check the medication against the prescription adequately and involve another pharmacist for a second check. This was a breach of the Code of Health and Disability Services Consumers' Rights.
"As a consequence of the dispensing error, [the woman's] health was affected adversely as a result of not taking her correct medication, and taking a medication that was not indicated, for a number of weeks before she was alerted to the medication error."
Allan recommended that the pharmacist undertake an audit of her accuracy in dispensing medication, and report back to HDC. He also recommended that the pharmacist provide an apology to the woman and commence a near-miss log, which she has done.