Man suffered for four months with STI that should have been diagnosed within days

Blood tests were done on the man but standard swabs weren't. Photo / 123RF

It took nearly four months for a man to be diagnosed with a sexually transmitted infection that a simple test could have detected within three days.

By the time the man in his 20s was finally diagnosed he had haemorrhoids, a sore throat, rashes on his palms and the soles of his feet and sores on his genitals.

The Health and Disability Commission today released its report into the incident which identified numerous failings by a rural DHB and its staff in getting the man tested for syphilis.

Syphilis is a bacterial infection usually spread by sexual contact. It starts as painless sores and, if left untreated, can develop into a rash and can result in damage to the brain, nerves, eyes, or heart.

The identities of those involved including the practice where this happened and even the specific dates are redacted by the commission.

Known as Mr A, he reported to the clinic in 2018 with haemorrhoids and rectal bleeding a week after having unprotected sex a week earlier.

The clinic is a GP-led clinic but the doctor was away for the day so he was seen by one of two registered nurses who alternate to provide leave when the doctor is away.

The man gave a urine sample and was tested for chlamydia and gonorrhoea. He also gave blood to test hepatitis B and C, HIV, and syphilis - however the standard practice throat and rectal swabs were not done as the nurse thought the man's bleeding would compromise the result.

Two weeks later Mr A turned up for his follow-up appointment, this time with a doctor.

He was told he'd need a repeat HIV test as the incubation period for that virus is longer - as it is with syphilis.

However, a syphilis retest was not mentioned to him.

The doctor told the commission that they'd had a family crisis that day and didn't think to bring up the need for a repeat syphilis test.

Fast forward several months and Mr A returned to the clinic with haemorrhoids, a sore throat, rashes on his palms and the soles of his feet and sores on his genitals - all symptoms of syphilis.

He was screened again and given a provisional diagnosis and told to refrain from sexual activity until the results came in a few days later.

Four days later the clinic had the results but didn't tell Mr A until a week later when he rang to find out about the outstanding result.

The deputy Health and Disability Commissioner said in her findings that throughout Mr A's sexual health journey he engaged with six different healthcare providers and, along the way, each provider let him down.

"While the individual omissions or errors in this case by each provider may seem small in isolation, they had the cumulative effect of delaying Mr A's syphilis diagnosis and treatment."

At the time of these events, the medical centre did not have a policy or procedure for reviewing test results. No policy existed for the setting of referrals or tasks, and rather the centre had developed an in-house system verbally over time. The medical centre acknowledged that it was following common practice rather than best practice, and has since developed new policies.

In her report the commissioner recommended that the DHB responsible conduct annual staff performance reviews, consider recruiting more staff and to apologise to Mr A.

The DHB told the commission that its paper-based system had affected its service to Mr A and that an electronic system would avoid processes that were prone to human error.

However, the DHB noted that other requirements have taken priority, and its limited financial resources may mean that the DHB is unable to progress work on an electronic system in the foreseeable future.