A Health and Disability Commissioner’s report released yesterday found that each of her three visits to the emergency department had some flaws in the care of women.
“I think the cumulative impact of these factors and the loss of opportunity represent a clear pattern of inadequate care due to SDHB as a service provider as a whole,” said Commissioner Morag McDowell. I am.
“I critically evaluated a woman’s presentations and, if they were performed, many over several presentations to coordinate appropriate investigations that would likely not have identified her rectal cancer. We conclude that many opportunities have been missed by SDHB clinicians. ”
The woman who was receiving chemotherapy for lymphoma at the time first went to ED for rectal bleeding on November 12, 2018, and returned again on December 10, 2019 and January 27, 2019.
Rectal exams were done every time, but no tumor was detected.
The day after her last trip to ED, the woman visited her GP. She detected her anomaly and made an urgent referral to a private gastrointestinal surgeon and endoscopist.
Eleven days later, the surgeon found a “significant mass” on the rectal wall and was later diagnosed with rectal cancer.
Ms. McDowall said the three doctors who examined the woman were relatively junior, but in the opinion of an independent expert, she could have been detected by feeling a tumor whenever she went to ED. Is.
“We cannot judge the validity of the tests performed in this case,” she said.
“More importantly, as outlined, routine rectal examination did not rule out rectal cancer and needed further investigation.”
The patient wrote to SDHB, stating that despite having received excellent treatment for the past decade, the missed diagnosis reduced confidence in the health care system.
“She said she wanted a direct apology from those who missed the opportunity to diagnose the tumor, repeating the impact of delayed diagnosis on her health.”
The board responded that it was disappointed that she missed the opportunity to diagnose her tumor early and said she would conduct a complete review of the referral process for colonoscopy.
Chris Fleming, CEO of SDHB, said the board accepted the HDC findings and deeply regrets missing the opportunity to diagnose.
“We arranged to meet the patient to sincerely apologize for the failure to provide care,” he said.
He said the board would accept the recommendations of all members and implement them within the time frame proposed by her.
This is the second similar harmful HDC report that has been treated in the SDHB Emergency Department in recent months.
In January, the Commissioner discovered that substandard care for a man in 2019 could have contributed to his death after doctors couldn’t detect the colon cancer that eventually killed him.
The patient was a man in his fifties, and his history of psychosis and the possible side effects of his medication contributed to a doctor who did not pursue the possibility that his pain was associated with cancer.
The patient had visited the ED seven times before his cancer was finally detected.
Caroline Collins, director of health care for women and children in SDHB Medicine, said the main function of the emergency department is to stabilize and treat acute patients.
“In this case, and in previous cases, patients were seen by specialists and emergency medical staff related to their condition, which is common with most patients looking through ED, depending on their needs.” Dr. Collins said.
“This means that it is incorrect to draw the conclusion that these two results indicate an ongoing problem with ED.”