Waitematā District Health Board has apologised to two patients and the family of another after losing their referral documents, causing them to wait months for urgent treatment.
One of the patients died after being diagnosed with thyroid cancer, another lost an eye and part of his skull after late treatment for a cyst under his eyebrow, and the third waited for more than a year for a follow-up cardiology appointment after suffering a cardiac arrest during a gallbladder operation.
Health and Disability Commissioner Anthony Hill has found that the three cases are "concerning examples of information being available but not actioned within the WDHB system".
He ordered the board to apologise for all three cases, adopt a fully electronic patient referral system and adopt a clear procedure to ensure that referrals are actioned.
DHB chief medical officer Dr Andrew Brant said the board accepted all the recommendations and adopted a fully electronic referral system jointly with the Auckland and Counties Manukau DHBs in March this year - four and five years after the three patients were lost.
The first patient, referred to as Mr A, was referred to the DHB by his family doctor in April 2013 with a 1cm cyst under the skin of his right eyebrow.
A doctor graded the case as priority one, to be seen urgently.
Despite repeated follow-up calls from his family doctor, the man was not seen until September 25.
In December his cancer was removed in an operation which required removing part of his skull and removing his eye.
The second patient, Mr B, was referred by his family doctor with a mass over his right thyroid in June 2014.
The DHB said the referral was never received by its Patient Service Centre, which prioritises referrals. But it was received by the radiology service which categorised it as "routine" and ordered an ultrasound for July 24.
This time a second referral with the abnormal ultrasound result was received by the Patient Service Centre, but because it was not aware of the earlier referral in June it logged it as priority two, to be seen within eight weeks of the latest referral.
His family doctor followed up a few days later asking for a priority review, saying the case was urgent. The referral was received but there was no evidence that it was referred to a doctor.
The family doctor asked for another priority review on August 19 saying the man was suffering discomfort swallowing, his voice was breaking and his throat felt tight at all times.
He was never seen by the hospital until he went in a crisis to the emergency department on September 12 and was diagnosed with thyroid cancer. The report does not say that he died from the cancer, but Hill ordered the DHB to apologise to Mr B's family.
The third patient, Ms C, suffered a cardiac arrest in November 2014 in a severe allergic reaction to an anaesthetic used for a gallbladder operation, but did not get a follow-up appointment until December 2015, more than a year later.
Brant said the DHB "extended its sincere apologies and, in one case, condolences to the families concerned".
"We have an organisational promise to deliver best care to everyone and we sincerely regret that we did not deliver the high level of care that we expect of ourselves in these instances," he said.
"Each case involved our manual patient referral process that was in place during those years. Work to upgrade the referral process to a more comprehensive electronic system started in 2013 – several months before the first complaint included in today's finding was brought to Waitematā DHB's attention.
"The fully electronic referral system was launched in March this year and gives DHB clinicians, as well as GPs, a visibility of the referral process that significantly reduces any risk of repeat future occurrences."