KEY POINTS:
A man died of throat cancer after doctors on six occasions failed to diagnose anything more serious than a sore throat.
Three years later, Deputy Health and Disability Commissioner Tania Thomas has decided to censure two of the man's doctors after a complaint by his widow.
The 28-year-old man, named only as Mr A, made seven visits to general practitioners at four medical centres between December 24, 2003, and January 24, 2004. Only after the last visit was he rushed for emergency care.
He died early in 2004, soon after being properly diagnosed with malignant lymphoma.
Neither the man's name nor the names of the doctors involved have been revealed.
Doctor F, the first doctor he saw on December 24, 2003, diagnosed a viral infection and sent him away with pain killers.
Two-and-a-half weeks later Mr A visited Dr B, at an accident and medical clinic where Dr B noted "big inflamed tonsils with heaps of almost black exudate", diagnosed tonsillitis and prescribed antibiotics and paracetamol.
Four days later on January 15, Mr A visited Dr C at the same clinic and received the same diagnosis, different antibiotics, and a medical certificate for another three days off work.
On January 24 Mr A had to be taken by ambulance to a rural medical centre for his seventh doctors' visit.
The doctor found a high fever, enlarged tonsils, a rapid pulse and sent him to the emergency department at a rural hospital, and then into intensive care.
He then had to be transferred to a city hospital's ICU.
In her recently released decision, Ms Thomas found Dr B, the second doctor to see Mr A, should have realised the "almost black exudate" was serious and taken further steps.
"The deficiencies in his care would be viewed with mild disapproval by his peers," she said.
Ms Thomas also found the care of Dr D, who saw Mr A on his sixth visit to a doctor on January 22, was inadequate under the Code of Health and Disability Services Consumers' Rights.
"It was clear to Dr D that Mr A had been unwell for over a week and was not improving despite receiving treatment from several doctors.
"In that situation... Mr A should either have received a closer follow-up from Dr D or been referred to secondary care."
The standard of treatment would be viewed with "mild to moderate disapproval" by Dr D's peers.
Ms Thomas said both doctors had reviewed their practices.
She ruled another doctor and an accident and medical centre had not breached the standards.
Both Doctors B and D apologised to Mr A's family.
"I feel I made a serious error of judgement and was insufficiently astute in not recognising and responding appropriately to the clues that were presented," part of Dr B's apology said.
Although Mr A had made seven doctors' visits, Ms Thomas decided only three doctors and one accident and medical clinic should be investigated.
She cleared the third doctor and the clinic of any wrongdoing.
- NZPA
