The woman visited her family doctor the next day, when he read her discharge letter and examined her. Although he intended to, the doctor did not refer the woman for an ultrasound or outpatient cardiology services, according to the report.
Two months later the woman visited the doctor for another unrelated ACC issue and he noted that she was still experiencing intermittent stomach pain. She told the doctor she had still not received her referral for the ultrasound. He then completed a referral to the DHB for an abdominal ultrasound. However, this was declined due to resource constraints, and the DHB advised that the doctor request a community ultrasound.
The doctor did not then refer the woman for a community ultrasound and had not referred her to outpatient cardiology services, which the woman was unaware of, despite her visiting the practice to see another doctor several times over the next few months.
Seven months after the initial referral was recommended, another doctor eventually referred the woman for a community ultrasound. This led to the discovery of multiple solid masses on her liver, and stones in her right kidney, and she was diagnosed with a rare form of cancer.
While the commissioner acknowledged the medical centre was busy at the time of these events, and there were staffing issues, she considered the doctor's management of the woman's referral was unacceptable.
"With patient safety as a priority, I consider that the doctor needed to ensure that he implemented strategies to mitigate the risks associated with a high workload," said McDowell.
"The repeated nature of the doctor's omissions to act on the advice and recommendations received from his colleagues suggest that his strategies were either ineffective or absent."
McDowell recommended that the doctor report back on additional strategies he has implemented to ensure referrals are acted on as soon as possible, and how the strategies will assist him during particularly busy periods and staff shortages.
- RNZ
