A woman in her 40s was forced to get a liver transplant after mistakenly stopping her medication early due to multiple failures by Capital and Coast District Health Board.
"I can't even begin to describe the catastrophic impact this has had on her life and
on the lives of her husband and children," her family said in a complaint to the Health and Disability Commission (HDC).
Today, the woman and her family, have won an apology from the DHB after New Zealand's health watchdog investigated the case and uncovered the errors.
HDC's decision said the DHB was in breach of HDC's consumer rights policy for failing in its care of the woman with lymphoma cancer.
The woman had a history of hepatitis B and required an antiretroviral medication to prevent the infection from coming back, as cancer treatments weakened her immune system.
It was intended that the woman would continue taking that medication for one year after chemotherapy but due to a number of systematic failures that didn't happen.
Instead, the medication was stopped early and the woman's hepatitis B returned. As a result, she required a liver transplant.
"We only hope that no one else will need to suffer in the same way again," the family said in the report.
Health and Disability Commissioner Morag McDowell was critical of the DHB for not providing inadequate information about continuing her medication but didn't address accusations of racism specifically.
"There was no clear plan to ensure the woman stayed on lamivudine following chemotherapy.
"As a consequence, her prescription for lamivudine was stopped too early and this went
unnoticed resulting in her hepatitis B being reactivated," McDowell said.
The commissioner recommended the DHB provide an update on the changes made as a result of this event, use an anonymised version of the report as a case study during education sessions, and provide a written apology to the woman.
The family also expressed concerns about "institutional racism" saying communication from the DHB was problematic as it was only verbal and English was the woman's second language.
A family member said medical staff also assumed she was to blame for not completing the course of medication which led to liver failure.
"This was completely inaccurate and demonstrates at the very least, unconscious bias on
the part of the staff concerned," they said in the report.
The DHB acknowledged the family's comments about institutional racism saying: "The DHB recognises it has an obligation to do better for Māori and Pacific patients who
unquestionably do experience inequitable health outcomes."
It also said risks in stopping the medication could have been done in a way the woman could better understand and remember.