Health NZ breached the code for not adhering to guidelines when it advised the woman of the wrong wait times for a colonoscopy.
The woman, identified as Mrs A, had a family history of colorectal cancer and was experiencing rectal bleeding and changed bowel habits when she went to her GP in September 2017.
She was referred to Waikato Hospital’s gastroenterology department and in November a consultant general and colorectal surgeon performed a sigmoidoscopy at Thames Hospital.
The doctor, identified as Dr B, reported the examination of the lower third of the intestine as normal but an expert hired by ACC later to assess a treatment injury claim by the woman found a “competently-performed” sigmoidoscopy would almost certainly have identified the cancer at that point.
“The alternate explanation that the rectal cancer grew extremely quickly from a non-visible lesion to a 4cm mass in only seven months is extremely unlikely both through the very low chance that a colorectal tumour can grow that fast, and the fact that the symptoms of rectal bleeding were present prior to the flexible sigmoidoscopy and continued and worsened until the cancer was discovered,” the expert told ACC.
“The bleeding was almost certainly due to the presence of a cancer or advanced polyp that was there the entire time.”
Two months later in early January 2018, the woman went back to her GP because of increased bleeding and a physical exam was normal, though the doctor did not undertake an extensive rectal examination because she was reassured by the “normal” sigmoidoscopy.
Mrs A was referred back to the gastroenterology department at Waikato Hospital with unexplained ongoing bleeding and this was referred to Thames Hospital.
There Dr B referred her back to Waikato Hospital with the referral going from general surgery back to gastroenterology in mid-January 2018 and triaged as category 4 – routine or usually seen within five to six months.
In a later explanation to ACC, Dr B wrote: “This patient had an absolute normal colonoscopy on August 27, 2015 and another normal flexible sigmoidoscopy on November 27, 2017. If she really has ongoing PR bleedings she probably requires a review by the gastroenterology department”.
Almost four months later Mrs A was seen by colorectal surgeon Dr C at Waikato Hospital who noted worsening symptoms since the sigmoidoscopy and the patient was “worried that there is significant pathology in her bowels that we have not found”.
Although he recommended in his clinic letter signed six weeks later on June 27, 2018, that she have another colonoscopy, he did not specify any urgency.
Caldwell’s report said the referral to Thames Hospital should have been for a procedure within 14 days but instead it was for within six weeks.
He also did not perform a rectal exam, proctoscopy or another sigmoidoscopy even though the physical exam should have been usual practice.
Dr C, a senior doctor, did not document his reasons for not conducting the physical exam or two procedures but told the HDC this decision was probably because there was a possible diagnosis of inflammatory bowel disease and she had a previous normal colonoscopy.
The ACC expert said if either a rectal exam or sigmoidoscopy had been performed the cancer would possibly have been identified and this contributed to another five-week delay in diagnosis.
The woman also did not give consent for a rectal exam but claimed that was because it was not explained to her properly.
The hospital advised Mrs A she could wait another four months so she paid for a private specialist to perform the colonoscopy, which found the tumour inside her rectum on June 12, 2018.
The lesion was removed five months later, but seven months later she was advised the cancer had spread to her lungs.
Caldwell found Dr C in breach of the code for not performing a rectal exam or second sigmoidoscopy and not documenting his decisions not to. The departure might have been minor if his referral for a colonoscopy had been urgent.
Health NZ Waikato was also found in breach for advising Mrs A she would likely wait four months for the colonoscopy even though Ministry of Health guidelines indicate her priority 3 referral should have meant a six-week wait.
Caldwell was also critical of Dr B, who has not practised since 2019, but did not find him in breach.
The deputy commissioner recommended Health NZ Waikato and the second surgeon apologise to the woman.
She also recommended the surgeon undertake an audit of clinical appointments for investigation of rectal bleeding to check physical examinations took place and were documented.
Health NZ said in a statement it accepted the report and was apologetic for the experience and outcome for the patient.
“We acknowledge this will have caused significant distress for the patient and we are sorry.”
The spokesperson said Health NZ and the surgeon had both now written to the patient to apologise.
“We will continue working through the commissioner’s recommendations – all of which we accept and will implement in the timeframes indicated in the HDC report.”
They confirmed the surgeon was undertaking an audit as recommended.
Health NZ Waikato was also in the process of auditing colonoscopy referrals as requested by the HDC. The audit results and recommendations will be reported to the HDC when completed.
“As requested by the deputy commissioner, we are auditing waiting times for elective colonoscopy over the previous 12 months.
“There is work under way to implement a programme that aims to prioritise the most urgent symptomatic colonoscopies in the short-term, and longer-term to reduce the demand for symptomatic colonoscopy.”
- RNZ
