A 67-year-old woman died of lung cancer after South Canterbury District Health Board "missed an opportunity" to diagnose her six years earlier - before it was too late.
Health and Disability Commissioner Anthony Hill found the DHB and Pacific Radiology in breach for failing to provide the woman was adequate care.
It comes after a Herald uncovered hundreds of Kiwi cancer patients receiving large taxpayer-funded payouts after being let down by the public health system - with more than $15 million paid in the past five years - after they were misdiagnosed, or not diagnosed quickly enough.
In October 2010, the woman was referred by her GP to South Canterbury emergency department investigate a possible pulmonary embolism (PE).
However, the tests showed it wasn't PD but found a "mass or mass-like" area in her lung. The doctor decided to treat her for pneumonia and recommended that she continue the current antibiotic treatment.
The discharge summary also recommended she get a follow-up chest X-ray in six weeks' time but the woman did not receive this information and said she had no recollection of being told this.
Hill was critical of the DHB saying there were a number of communication breakdowns from which lead to the six-week follow-up not happening.
"This led to a missed opportunity for additional investigations, and a probable delayed diagnosis of cancer," Hill said.
Five and a half years later she returned to her GP with a three-week history of upper respiratory symptoms, and was prescribed antibiotics.
She came back a month later with discomfort in her right upper quadrant and heartburn. As a result, she was referred to the DHB for a semi-urgent ultrasound (US) scan of the abdomen in relation to classic gall-bladder symptoms - but was put on a wait list.
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The DHB outsourced the referral to Pacific Radiology on June 22, 2016. Two months later she was sent a letter for an appointment that wasn't until September 21.
Hill's investigation found the DHB did not have systems in place to manage and monitor the outsourcing of scans, and there was a lack of verbal, physical, and electronic communication to the woman and her GP about the wait.
During this time, the woman had been ringing Pacific Radiology so see if she could pay for the scan as her symptoms were getting worse, but was told there was no way and she would have to wait.
Eventually, after jumping between services for another two months, she was found to have adenocarcinoma of the lung with right sacral metastasis. She was referred to a radiation oncologist but it was too late. She died in 2017.
During a serious adverse event review undertaken by the DHB, the woman said she had no recollection of being told that a repeat chest X-ray was recommended, or to see her GP again.
She said that there was "no way" she would have ignored the result of the 2010 CT scan had she known more clearly what it contained, in particular the word "mass".
It should have been made clearer to her and put in writing, she said.
Hill recommended that the DHB provide an update on the recommendations in their own review of this case.
He also asked they provide an update on the outsourcing agreement with the radiology service, undertake an audit and apologise to the woman's family.
The radiology service was asked to do the same.
South Canterbury DHB chief executive Nigel Trainor told the Herald the DHB took all adverse events seriously and a significant number of changes had occurred since 2016 to mitigate such situations in the future.
"The SCDHB are currently meeting the acceptable timeframe of 2-4 weeks for semi-urgent ultrasounds."