A man was admitted to Dunedin Hospital four times with bleeding from his rectum but he still had to wait almost 13 weeks for a colonoscopy. Photo / RNZ
A man was admitted to Dunedin Hospital four times with bleeding from his rectum but he still had to wait almost 13 weeks for a colonoscopy. Photo / RNZ
A man with a family history of bowel cancer was admitted to Dunedin Hospital four times with rectal bleeding but despite meeting the criteria for an urgent colonoscopy he waited almost 13 weeks, delaying his diagnosis and treatment for colon cancer.
He was eventually telephoned by a nurse and told his cancer was terminal and he had about six to 12 months to live.
The man, in his 70s, and his wife were distressed by not receiving the devastating news in person and complained to the country’s patient rights watchdog about the care from Te Whatu Ora Southern that led to the delayed diagnosis.
In a report released today, Health and Disability Commissioner [HDC] Morag McDowell found Te Whatu Ora Southern breached the man’s rights to services of an appropriate standard and recommended it apologise to the man and his family.
And, McDowell noted there had been problems in the same region with access to diagnosis.
In 2018, the then Southern District Health Board [SDHB] commissioned an external review of issues raised by surgeons in Southland relating to restricted access to colonoscopy services.
Following publication of the review in 2019, the DHB commissioned two further reviews of the service in 2020.
All three reviews identified that access criteria for colonoscopy services at SDHB were being applied too strictly, with patients being declined colonoscopies inappropriately.
In the case of the man, who is unnamed in today’s report, he first went to Dunedin Hospital in April 2018 with rectal bleeding but the bleeding settled while in hospital and he was referred to an outpatient clinic with the expectation by clinicians he would receive a colonoscopy - when a camera is inserted into the large bowel to check for cancer.
He’d last had a colonoscopy in 2014 and polyps, harmless clumps of cells that form on the lining of the colon but which over time can turn into cancer, were removed.
Instead, he was sent for a CTC, an X-ray of the large bowel which showed diverticulosis; small bulging pouches in the digestive tract that can be managed through diet.
The DHB told the HDC that such an X-ray was considered to be “as good” as a colonoscopy in diagnosing colon cancer.
More than a year later in June 2019, a blood test indicated the man was low in iron and he was suffering from upper abdominal pain so he was referred for a gastroscopy.
An appointment was scheduled for August 5 that year but it didn’t happen because the man was admitted to hospital on August 2 with so much rectal bleeding he required three units of blood.
An in-patient gastroscopy indicated no immediate cause for the bleeding though the man disputed he’d had the procedure.
Health and Disability Commissioner Morag McDowell found the former Southern DHB in breach of the Code of Health and Disability Services Consumers' Rights. Photo / Dean Purcell
The man was referred for an outpatient colonoscopy but it was booked for November 5, almost 13 weeks after referral.
During that time he was admitted to Dunedin Hospital twice more with rectal bleeding but doctors decided to wait for the booked colonoscopy.
It showed a mass that was colon cancer and surgery on December 4 found the cancer attached to the man’s stomach wall.
In May 2020, during and because of the first Covid-19 lockdown, a specialist nurse informed the man and his wife over the phone the cancer was terminal and that he had between six and 12 months to live.
McDowell said the DHB failed to follow its own guidelines and those of the Ministry of Health at the second admission in August 2019 because the man fulfilled the criteria for an urgent colonoscopy within two weeks.
This delayed the man’s diagnosis and treatment by 10 weeks and the DHB admitted it was “unfortunate and too long”.
The DHB said the low urgency was possibly due to reliance on the CTC findings of diverticular disease.
ACC accepted the man’s treatment injury claim with its expert finding the man should have had a colonoscopy soon after his April 2018 admission.
However, McDowell accepted the findings of her expert, general and colorectal surgeon Dr Christoffel Snyman, that the CTC and gastroscopy were reasonable and appropriate.
But Snyman found in August 2019 the man’s colonoscopy should have been urgent and if not performed in two weeks it should have been done within six weeks, taking into account the CTC finding the year before.
Though it was unlikely an earlier colonoscopy at that stage would have altered the outcome, it was a moderate deviation from the accepted standard of care.
In making the breach finding, McDowell said she was aware of the pressure faced by colonoscopy services at a national level due to an increase in demand combined with workforce shortages and recruitment challenges.
“Fundamentally, however, it is my view that when investigations are clinically indicated as urgent or semi-urgent, healthcare consumers have the right to expect such investigations to be scheduled sooner than occurred in this case.
“That such delays are common does not excuse the delays, and I am concerned that if a culture of tolerance of unacceptable delays develops across localities, this will become normalised and patients will be put at risk.”
Timely colonoscopy access was a critical systems issue, she said, and timely diagnosis was particularly important for reducing suffering and death in cancer patients.
“... often it is a key factor in survivability. Long waits for diagnostic procedures can also have a significant psychological impact on patients and their whānau, who may be concerned that they have cancer”.
Te Whatu Ora Southern quality and clinical governance solutions director Dr Hywel Lloyd accepted the report findings and said the organisation had taken significant actions to improve access to colonoscopy services for the Southern community.
“We sincerely apologise to the patient and their whānau for the distress caused during this time. Any delay in health care is very concerning for any patient.”
He said Te Whatu Ora Southern was in the process of implementing McDowell’s recommendations including providing the HDC with an update on current wait times for colonoscopy services.
Natalie Akoorie is the Open Justice deputy editor, based in Waikato and covering crime and justice nationally. Natalie first joined the Herald in 2011 and has been a journalist in New Zealand and overseas for 27 years, recently covering health, social issues, local government, and the regions.
