Mr Hill's investigation into a complaint laid by the man's daughter found that he went to a GP on April 20, 2012, complaining of excessive toilet use, weight loss and rectal bleeding.
The GP referred him by fax to the Waitemata District Health Board's gastroenterology outpatients department for assessment.
"However the DHB said that the referral was not received."
On April 24, 2012, the man went to the ED with a painless right groin swelling. The ED specialist obtained a different medical history from the one obtained by the GP and concluded Mr C had a hernia. The man was referred to the general surgery department which declined to see him because of what Mr Hill refers to as "waiting list management".
The GP misinterpreted an electronic message from the hospital about that as referring to the earlier gastroenterology referral.
When Mr C was reviewed by a locum colleague of the GP's at the same medical centre on July 2, 2012, the locum, who noticed the original referral, instigated a new referral for gastroenterology assessment.
On July 29, the DHB told the GP electronically that the referral had been given "P2 priority - to be seen within six weeks", Mr Hill said. "The waiting time for the appointment was deemed 'unknown'.
"The DHB had taken 26 days to triage, grade, and communicate a decision back to the referrer. The DHB said that expected waiting times were noted as 'unknown' because of long waiting lists and it had been unable to provide GPs and patients with a time in which the patient would be seen."
On August 17, the man was seen at the medical centre by a locum who was aware he was awaiting a gastroenterology assessment.
On September 11, 2012 the man went to the public hospital ED with blood in his urine and his liver was found to be enlarged.
Mr Hill said: "Mr C had still not received an appointment for specialist gastroenterology review, and it was then nine weeks since Waitemata DHB had graded the referral as P2 priority on 12 July 2012."
The ED specialist noted the man had lost 14kg in a year, had poor appetite, a swollen right leg, a hernia, bowel habit alternating between constipation and mucousy, bloody, loose stools. In a rectal exam, she found a "firm craggy mass".
She suspected rectal cancer and referred him to another hospital.
Mr Hill found the DHB and the GP breached the code of patients' rights.
Mr Hill says the DHB told him it had done a lot of work to manage its colonoscopy waiting list, including recruiting technically-skilled nurses, redesigning the working pattern of senior doctors to provide extra capacity, a review of our gastroenterology waiting lists to ensure cases have been given the appropriate grading, and introduction of a revised grading system.
"... At the time [Mr C] was referred for a colonoscopy the Ministry of Health's ... wait time indicator was for 50 per cent of P2 [non-urgent] patients to have their colonoscopy within six weeks," the DHB told Mr Hill. "It was not possible for Waitemata DHB to say, when advising patients that their referrals had been accepted, whether they would be among the 50 per cent who would be seen within six weeks. The current ministry wait time indicator for colonoscopy for P2 patients is 60 per cent within six weeks and there is still no maximum waiting time. Nevertheless Waitemata DHB can now advise that we expect that all P2 colonoscopies are undertaken within four months."
The target has subsequently been increased to 65 per cent within six weeks.
Waitemata DHB chief medical officer Dr Andrew Brant said the DHB fully accepted the findings.
"The DHB has extended our condolences and apologised to the patient's family for not providing a clear timeframe to the patient on when to expect to be seen. "
As a result of the Dr Brant said the DHB now provided clarity to patients and their GPs about the expected timeframe in which patients are seen.
"Also, we provide advice to patients on what they should do if their condition changes or if they have any concerns."
"Within our district, primary care is currently implementing an electronic referral system giving immediate notifications to GPs when their referral is received. If this had been available in this instance, the GP concerned would have known their initial referral had not been received by the DHB."
