A general practitioner, an anaesthetist and the MidCentral District Health Board have breached the health code after a man with cancer died when a referral for further scans was not carried out properly.

Health and Disability Commissioner Anthony Hill released a report today finding them in breach of the Code of Health, saying the DHB's system for managing referrals was inadequate, and that the DHB failed to "ensure quality and continuity of services".

Hill said the anaesthetist's record-keeping was inadequate "in a number of areas" and that "he had failed to keep clear and accurate patient records in accordance with his professional obligations", while the GP "failed to provide services with reasonable care and skill".

The man who died had previously undergone chemotherapy and had his oesophagus and part of his stomach removed, and had a feeding tube inserted.


About six months after the surgery the man's condition began to worsen and he visited his GP to request a scan.

The GP sent a request for a scan to a public hospital but failed to provide any information about the man's symptoms or any assessment findings.

The DHB then did not take action on the scan as the referral was misplaced.

A month later, the man reported new symptoms to his GP, including a "sharp burn" at the back of his throat. The GP then resent the initial referral.

There was no indication of the man's declining health or the urgency of the request, and the referral letter was left on the surgeon's desk until he returned from leave about a month later.

The man then underwent the scan, which showed the cancer had returned. Further investigations showed a blockage in the man's upper abdomen.

He then underwent a laparoscopy, but the surgeon was unable to complete it due to the recurrent cancer. The man never regained consciousness, and later died.

Hill recommended that the GP organise a random audit of 10 referrals and to attend training on communication, and that the DHB review the effectiveness of a number of its measures, including a centralised referral process for tracking referrals.

Hill also recommended that the anaesthetist undergo further training on record-keeping, that the surgeon review his follow-ups after surgery and that the GP, anaesthetist and DHB each apologise to the man's wife for their breaches of the health code.