Woman dies of cancer four weeks after visit to GP who failed to examine her

There should have been high suspicion of cancer when the woman presented to the GP with difficulty swallowing and unable to speak, an expert said. Photo / 123rf

A woman who presented to her GP barely able to swallow wasn’t examined, nor had her vital signs measured, despite being so unwell that she died just four weeks later.

The woman had esophagal cancer but didn’t know it and the cancer was only identified when she presented to a hospital emergency department unable to swallow liquids.

The Health and Disability Commissioner (HDC) launched an investigation after a complaint from the woman’s husband, who said the medical practice should have picked up on the cancer earlier.

According to findings from Aged Care Commissioner Carolyn Cooper, the woman first sought care from a part-time GP at a medical practice.

The name and city of the practice, as well as the dates of the visits, were not detailed in Cooper’s findings released today.

The woman, in her 60s at the time, initially complained of loss of appetite, a 7kg weight loss over two months, and feeling cold with tingling limbs.

The GP ordered blood samples and an ultrasound of the woman’s liver. Medical notes stated she was a heavy drinker.

The doctor told the HDC the woman didn’t show signs of difficulty swallowing at the time.

Her blood results came back with some minor thyroid concerns, and the hospital gave her ultrasound referral low priority with a likely 30-38 week wait.

In a letter, the hospital told the woman’s doctor to review this prioritisation, but it was sent to the wrong practice.

It meant the doctor never saw the letter. If she had, she told the HDC she would have phoned the hospital and asked for an earlier appointment.

Exactly three weeks after the first visit, the woman and her husband returned to the doctor’s practice and she was seen by another doctor.

Too weak to communicate herself, the woman’s husband told the doctor that his wife could not swallow solids, could barely manage liquids, and was losing more weight.

The doctor didn’t examine her, because he said this had been done at the earlier visit. He prescribed her thyroid medication and scheduled a follow-up appointment in six weeks.

The doctor later told the HDC that he told the woman she should be admitted to hospital, but she refused as it was a public holiday.

The woman’s husband denied the suggestion of hospital care was ever made. It was never recorded by the doctor in the patient’s notes.

Five days after this visit, the woman’s condition worsened. She was taken to the hospital’s emergency department and was later diagnosed with metastatic oesophageal cancer with liver and lung metastasis, which meant the cancer had spread to those organs. She died three weeks later.

In her opinion, Cooper found the doctor who initially saw the woman reached a reasonable conclusion as to her condition.

Her symptoms were in line with prolonged heavy alcohol consumption and there was no suggestion of indigestion.

But the same couldn’t be said for the second doctor’s visit.

A doctor who provided the HDC with his expert independent view of the patient notes said there were indications for an urgent gastroenterology assessment with a high suspicion of cancer.

The second GP’s failure to record vital signs or examine the woman would be met with “moderate disapproval” from other doctors.

Cooper concluded the doctor breached the Code of Health and Disability Services Consumers’ Rights by failing to adequately examine the patient.

She said the rapid deterioration of the woman’s illness meant even if a gastroenterology referral was made it would have been too late.

But it would have given time for the woman and her family to adjust to the diagnosis.

The doctor said since the incident he had undertaken further medical training on record keeping.

Cooper recommended that he provide an apology to the husband and review guidance on conditions that have symptoms of swallowing problems.

Ethan Griffiths covers crime and justice stories nationwide for Open Justice. He joined NZME in 2020, previously working as a regional reporter in Whanganui and South Taranaki.