A GP has been faulted for not following up, for eight weeks, an abnormal test result from the blood of an elderly man who later died of stomach cancer.
"Dr C" is one of two GPs found by Health and Disability Commissioner Anthony Hill to have breached the code of patients' rights in their care of the man, aged 81 at the time.
In his no-names report, made public today, Mr Hill says slightly low haemoglobin was detected in a blood test ordered by his GP, "Dr B", in May 2011.
A pattern of similar results became established over the the next 17 months, although one result was normal; Dr B twice prescribed a course of iron supplements for mild anaemia.
In December 2013, the man transferred to Dr C, who ordered a blood test. This revealed a significantly abnormal haemoglobin level.
"Dr C did not take action on the abnormal result until February 14, 2014 -- when he was reminded of the result a second time by his practice nurse -- at which point he asked Mr A to return for a follow-up appointment," Mr Hill says.
The GP referred the man for urgent investigations, which revealed a malignant stomach tumour. While the man was waiting for further investigations to determine the stage of the cancer, new symptoms emerged and a CT scan revealed the disease had spread to his brain.
"Sadly, Mr A died later that year."
Mr Hill says Dr B's breaches of the code were his failure to take steps to find the possible underlying cause of his patient's anaemia, not organising follow-up to assess his response to treatment and failing to discuss with the man the potential implications of the results of blood tests taken in October 2012.
Dr C's breach was the nine-week delay in following up the abnormal December 2013 test results.