A new mother who returned to hospital twice after a Caesarean section for fluid leaking from her vagina, was sent home either undiagnosed or misdiagnosed because of systemic deficiencies at a district health board.
It wasn't until four months after the birth that a necessary scan found a rare complication caused by the Caesarean, a ureterovaginal fistula - an abnormal channel between the ureter and vagina causing the leak and discomfort.
The woman, known as Mrs A, told an investigation by the Health and Disability Commissioner the leak was so bad "that her skin was peeling because it remained wet all the time".
In her decision released today, Deputy Health and Disability Commissioner Rose Wall ordered Counties Manukau District Health Board to apologise to the woman for not providing her with services of reasonable skill and care.
The DHB denied it had breached Mrs A's rights under the Code of Health and Disability Services Consumers' Rights, but Wall said clinicians failed to correctly diagnose and appropriately treat the patient twice.
The woman had the Caesarean in 2019. Her baby was born healthy and she was discharged two days later.
A month later she returned to Middlemore Hospital with a breast infection and vaginal leakage, which was clear fluid.
She underwent an ultrasound scan but despite Mrs A's catheter being clamped during the procedure, the bladder remained under-filled and was unable to be adequately assessed.
This meant Mrs A's ureteric jets could not be visualised. The radiologist, Dr E, noted there was swelling of the kidney and enlargement of the ureter - a tube that carries urine from the kidney to the urinary bladder.
Following the scan obstetric registrar Dr B undertook a blue dye test which ruled out a vesicovaginal fistula - an abnormal opening that forms between the bladder and vaginal wall - but it did not rule out a ureterovaginal fistula.
She also noted "normal ureteric jets" despite the radiologist being unable to view them.
Dr B later told the Deputy Commissioner she must have been told the jets were normal by the radiologist but Dr E said there was no mention of this in her report and she would only have given a verbal report in the event of an emergency, which the case was not.
The dye test findings and scan results were discussed with Dr D, the on-call consultant, who later said if she had been made aware of the swollen kidney and enlarged ureter she would have ordered more investigations.
The leak was noted as almost resolved on the second night and Mrs A was discharged to the care of her midwife early the next morning before a doctor could see her again.
However, Mrs A disputed that she was discharged to the care of her midwife and said "no one had any idea what was going on".
Less than two weeks later she returned to the hospital with mastitis and the leak, which soaked a pad every three hours.
Despite the radiologist's report that the bladder [and ureters] could not be assessed, a Senior House Officer relied on Dr B's incorrect notes that the ureteric jets were normal.
More tests again ruled out vesicovaginal fistula and after six days in hospital Mrs A was keen to go home and discharged with likely lochia alba, vaginal discharge after birth.
Three weeks later her GP referred her to a gynaecology service for vaginal fluid loss, she was sent back to hospital for an MRI the following month and later underwent a CT urogram, which finally confirmed the ureterovaginal fistula.
Four months after the birth she underwent surgery to re-implant the ureter.
Counties Manukau DHB strongly disagreed the delay in Mrs A's diagnosis was in breach of Right 4 of the Code and said a delayed repair such as in this case allowed inflammation from the injury and subsequent urine leakage to subside, increasing the chance of a successful repair.
It said it was not unusual for patients to be discharged from hospital without a definitive diagnosis, especially when the symptoms appeared to be resolving or resolved.
But Wall accepted the advice of her expert, obstetrician and gynaecologist Dr Ian Page, who said the standard of care was not consistent with accepted standards, and where a diagnosis was not reached a plan for further investigation and assessment should be put in place.
"The failure to reach a clear diagnosis on both admissions in [Month 2] occurred because the need for a CT urogram to diagnose/exclude a uretero-vaginal fistula was not recognised," Page said.
This was despite the dye and other tests that ruled out urinary incontinence or urine being the leak.
He also noted the diagnosis of lochia alba was not consistent with Mrs A's presentation, as vaginal discharge after birth is usually not clear and reduces in amount as time
Wall was critical of the care provided to the woman over the two hospital admissions, and the extended time it took the DHB to reach the correct diagnosis for her presenting symptoms, particularly as they persisted over an extended period without resolution.
She expressed concern about Counties Manukau DHB discharging the woman without appropriate outpatient follow-up in place, and fixing on a diagnosis that was not consistent with the presenting symptoms.
"These deficiencies demonstrate missed opportunities to investigate the cause of the woman's symptoms fully or place her on the correct diagnostic pathway," Wall wrote.
She recommended the DHB apologise to the woman, and implement a clinical pathway for suspected vaginal fistulas to guide clinicians on the appropriate tests and imaging to request, and examinations to undertake.