The patient was placed under the care of a consultant physician, who ordered an ultrasound scan.
A question around ovarian cancer was listed in the 'to be answered' section of the scan request - which was given priority status. There were no other mention in historical clinical notes of the cancer being considered as a cause for her symptoms.
The physician told the commission they had not discussed the possibility of the cancer with the patient at the time, due to her having a history of anxiety and depression.
Their initial plan to discharge their patient after an ultrasound scan had been performed was cancelled, and instead the woman was discharged by a house officer prior to the scan being carried out.
Instead, it was arranged for her to have an ultrasound scan of her abdomen and pelvis as an outpatient. The request for this scan had no reference to cancer and it was not requested that the report was copied to her GP, either.
The discharge summary notes for the patient said the diagnostic impression was of a viral illness, and her GP was to follow up on the result of the scan. Again, no mention of ovarian cancer was made.
The physician told the commission he did not recall being made aware of those arrangements.
Two months later the patient had her scan. The report that followed noted a mass which was "likely to be of ovarian origin" and it recommended further action.
Neither the patient, nor her GP received the scan or the report relating to it. The radiologist did not report the result to the doctor at the hospital, nor the house officers who arranged the scan.
Almost 12 weeks after the patient was discharged from hospital the ultrasound report was viewed and accepted by the physician, but there was no evidence they took any action.
In January 2015 the tumour was detected by the patient's GP, who urgently referred her for an ultrasound scan.
This uncovered a large ovarian mass. The woman underwent surgery and was diagnosed with high-grade serous carcinoma of the ovary.
The incident was investigated after the patient queried why the tumour had not showed up on her ultrasound scan a year and a half before.
In a report following the investigation, Hill said the doctor had breached the patient's right to be fully informed about their condition, as well as her right to services of an "appropriate standard".
He recommended the DHB provide the commission with a report outlining steps it had taken to improve communication systems and educate staff about documentation.
A second recommendation was that the doctor at fault undertook a "random audit of a selection of radiology test results" to ensure the patient radiology test results he had received in the past three weeks were adequately followed up.
Hill also advised both the doctor and the hospital write an apology to the patient's family, for their breach of code.
