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Cancer diagnosis missed by ED

Rachael Kelly rachael.kelly@stuff.co.nz

A man went to a hospital emergency department seven times in six weeks, but the Southern District Health Board staff and a general surgeon missed opportunities to diagnose him with colon cancer.

The man later died of the disease.

A report released by Deputy Health and Disability Commissioner Vanessa Caldwell into the incident says while a diagnosis may not have changed the outcome, it could have opened up opportunities for palliative care that could have led to a significantly different end to the man’s life.

The health board and the surgeon were found to be in breach of the Code of Health and Disability Services Consumers’ Rights.

Southern DHB Chief Executive Chris Fleming said the board accepted the findings of the HDC complaint and wished to extend its deepest apologies to the family of the patient and the organisations which provided support and care for him in the community.

The man, who was in his 50s, had a history of schizophrenia and chronic thought disorder, and lived in a community residential mental health service.

During a six-week period he presented to the Emergency Department seven times with severe abdominal pain. He was repeatedly diagnosed as having constipation as a result of an antipsychotic medication (clozapine), the report says.

At each presentation the man’s diagnosis remained the same, despite lack of improvement and other red flags indicating something else may be causing his pain.

Each staff member failed to question the previous diagnosis or undertake further investigations until he underwent surgery to examine the abdomen, the report says.

During the surgery the man was found to have widespread colon cancer with tumours causing a complete obstruction of the bowel.

The man died of septic shock, secondary to metastatic colon cancer, the report says.

The Deputy Commissioner considered that there were numerous missed opportunities by many Southern DHB clinicians, across multiple presentations, to investigate the man’s symptoms further and reconsider his diagnosis when he failed to improve.

‘‘The cumulative effect of these missed opportunities demonstrates a concerning lack of critical thinking and acceptance of the man’s unimproved condition by SDHB staff, attributable to the DHB as the overall service provider, Caldwell says.

‘‘I acknowledge that the man’s illness was metastatic, and that an earlier diagnosis many not have influenced the ultimate outcome. However, I note that an earlier diagnosis of colon cancer could have opened up opportunities for palliative care that could have led to a significantly different end to this man’s life.’’

Caldwell recommended the board provide HDC with any protocols or procedures that have been developed as a result of meetings it had since had with mental healthcare providers from the community, provide evidence of relevant staff training and orientation to new protocols and procedures, and that an anonymised case study of this case be presented to all emergency department and general surgery staff at the public hospital for educational purposes.

She also recommended that it implement a new policy/procedure about the use of CT scans in ED, and consider how the DHB can improve the continuity of care in situations where a patient presents to hospital multiple times.

Fleming said the event was raised with the board via the HDC process by the community organisation involved in the man’s day-today care and support.

News

en-nz

2022-01-18T08:00:00.0000000Z

2022-01-18T08:00:00.0000000Z

https://fairfaxmedia.pressreader.com/article/281556589193780

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