A damning report has found the Bay of Plenty District Health Board failed a patient by not carrying out an ultrasound that may have identified a deadly tumour on his liver.

Health and Disability Commissioner Antony Hill, who released his report yesterday, said the district health board failed in the care it had provided to the patient.

In doing so the district health board breached the Code of the Health and Disability Services Consumers' Rights, Hill said.

Hill's report said that the patient, referred to as Mr A, had been receiving hepatoma ultrasounds and three-yearly surveillance endoscopy at the district health board.


His doctor decided in November 2011 that a repeat hepatoma ultrasound was required and intended for the patient to have one in six months' time when he had his next endoscopy.

But before the patient could have the required endoscopy, the district health board suspended all surveillance endoscopies in April 2012 due to "resource constraints".

That included the resignation of a staff member and the death of another within the gastroenterology team.

This resulted in Mr A's intended hepatoma ultrasound not being ordered, and a notice about the suspensions was also placed on the district health board's website.

The board notified the man's GP, and in May 2012 a staff member from the GP's clinic phoned Mr A and offered him the choice of a private endoscopy.

But the patient refused as he was not symptomatic and wanted to leave it at that stage.

In July 2015, the patient consulted another GP who arranged for an appointment at the district health board, and Mr A was referred for a scan, and the 7.5cm tumour found.

Mr A was referred for palliative care.

Hill said he considered that the district health board was responsible for the operation of the clinical services it provided and for service failures.

"The DHB has an organisational duty to facilitate continuity of care and is responsible for ensuring it has robust systems in place to provide an appropriate level of care," he said.

Hill made a number of recommendation to the board about its processes for monitoring patient surveillance.

That included developing a standardised protocol for follow-up for all patients with a cirrhotic liver disease, conducting a review of the effectiveness of the protocol. Plus a database for patients on dual surveillance programmes should be implemented.

Hill's report confirmed the district health board had apologised to the patient.

In a written statement, the Bay of Plenty District Health Board's chief executive, Helen Mason, said the board had extended its sincere apologies to Mr A and his family.

"We acknowledge that we failed as an organisation in this instance to provide a consistent standard of surveillance care and communication," Mason said.

"We acknowledged the distress this caused them and how deeply sorry we are for this."

Mason said the district health board took these matters seriously.

"When we became aware of this, a review was undertaken to ensure no other patients were impacted in the same way.

"We have taken the learnings from both our internal investigation and the Health and Disability report and are implementing the recommendations."

Mason said the board had made changes to its process since 2015 to ensure this does not happen again.