Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint on behalf of the complainant's deceased mother-in-law. The complaint is that in November 1997:
- the late Consumer was not admitted to Hospital for the treatment of dehydration and vomiting
- A General Surgeon failed to accurately diagnose terminal stomach and liver cancer in the Consumer.
The complaint was received on 14 January 1998 from the Consumer's daughter-in-law. An investigation was commenced and information obtained from:
The Complainant/Consumer's daughter-in-law
The Consumer's daughter
The Provider/General Surgeon, Hospital
The Chief Executive Officer, Hospital
The Consumer's General Practitioner
The Commissioner sought advice from a Medical Physician and Surgeon.
Outcome of Investigation
In 1990, the Consumer had a partial gastrectomy for stomach cancer and was discharged from follow up for this in 1994. Following this operation, the Consumer appeared to be doing well until 1997 when she began to suffer from nausea, vomiting and weight loss. In mid-October 1997 when she visited her GP, a return of the Consumer's malignancy was suspected and an urgent barium meal requested.
The barium meal was performed nearly three weeks later in early November 1997. The Hospital's guidelines on prioritising referrals for barium studies state urgent requests should be performed within a week of receiving the referral. The GP's referral letter clearly stated this was an urgent request.
The Consumer's GP received the report from the barium meal the next day. The report stated, "Appearances are suspicious for recurrence of carcinoma with mucosal fold infiltration at the anastomosis site extending proximally. Alternatively, these changes could be inflammation".
The same day, the GP then telephoned and wrote to the Provider, a General Surgeon at the Hospital. The GP noted, "Spoke to [General Surgeon]. Can only be admitted or seen next week".
The General Surgeon saw the Consumer three days later and performed a gastroscopy the next day. The Surgeon advised that he found no evidence of anastomotic stricture nor any evidence of recurrent cancer in the stomach. Biopsies were taken which showed changes consistent with biliary reflux and no evidence of cancer. As a result treatment options were suggested to take into account the Surgeon's findings.
The Consumer's family report that she was not given a physical examination nor were diagnostic blood tests carried out despite her previous history of stomach cancer. There is no evidence in the notes given to the Commissioner that a full physical examination was undertaken. The Consumer's daughter reported that the General Surgeon saw her and her mother briefly after the gastroscopy to report that ulcers were found and not cancer, and that the Consumer was to start on some new medication. They were not informed the medication was to be used on a trial basis or that they should contact the hospital again if the symptoms persisted.
The following day the Consumer was phoned by the hospital to check on her condition according to their usual procedures. The clinical notes record there was no answer at this time. There was no further follow-up.
That same day Consumer visited her GP who gave the results of her biopsy which showed no signs of ulcer, cancer or obstruction. The Consumer's GP also commented in his notes that the medication prescribed by the General Surgeon "…helps for vomiting".
The General Surgeon advised that during the time he saw the Consumer he did not observe signs of dehydration although he was concerned about her weight loss. The General Surgeon recalled that neither the family nor the GP requested the Consumer be admitted to hospital, and he considered that if they had done so, there would have been no problem in having the Consumer admitted.
The General Surgeon stated that he considered that once he had instigated the drug treatment, the family would contact the GP again if the symptoms persisted, and other management alternatives could be indicated, such as a referral for a CT scan.
The physician advising the Commissioner stated that:
Given her age, past history, and upper gastrointestinal symptoms prior to the endoscopy, a fuller assessment of the patient was required. Given the results of the preceding barium meal, if clinical assessment had confirmed weight loss and dehydration [the consumer] should have been admitted for further investigations and management.
Following release of an opinion, the Commissioner decided a review by an independent surgeon was more appropriate. This was sought and the surgeon advising the Commissioner stated that:
[The General Surgeon] acknowledges … that he received an urgent referral after a telephone call from the GP because of symptoms of increasing nausea and inability to keep food down over a period of weeks. He was aware that the barium meal report indicated a significant outlet obstruction. The urgency of referral appears to be on the basis of a concern about recurrent cancer, rather than about the actual clinical status of the patient. The referral letter by the GP [early November] indicated a problem with chronic vomiting and a possible fullness in the epigastrium. There was no concern expressed about hydration status. The referral for the barium study [ten days later] had mentioned "loosing weight, chronic vomiting and pain". The GP's notes indicate there was no haematemesis.
… Endoscopy did not find evidence of a stricture or evidence of recurrent cancer. The findings of the barium study were not confirmed. It was reasonable, in the first instance, for [the General Surgeon] to act primarily on the basis of the endoscopy findings.
The medication given to [the Consumer] was reasonable, given the findings of the endoscopy. Maxolon (for nausea and to encourage gastric emptying) and Ranitidine (to reduce acidity and gastric content volume). The findings of the barium could have been explained by the benign peptic stomal ulceration, which was not seen on endoscopy. The possibility of it was covered by prescribing Ranitidine.
The prescription of these drugs and the request for GP follow-up was not unreasonable. …
Two days following the endoscopy the GP saw [the Consumer] and noted that the medication "helps for vomiting". The findings on examination at that time indicated no need for admission (BP 130/70, pulse 100, regular).
From the evidence there does not appear to have been an indication for admission at the time that [the General Surgeon] saw [the Consumer]. I understand that admission was not requested by the GP, [the Consumer] or the family. There was no evidence of dehydration, at the time that [the General Surgeon]… or the GP… saw [the Consumer].
Following the Consumer's discharge after her gastroscopy there is no documentation for follow-up arrangements apart from the note, "She is to have a trial of regular Metocolpramide [anti vomiting medication] and Ranitidine [anti-ulcer medication]." The Consumer saw her GP the next day.
My surgeon advisor states:
The responsibility for determining the response to the medication was handed to the GP, as indicated in [the General Surgeon's] letter to the GP after the endoscopy. Only if there had been concern about the compliance or reliability of the patient or of the diligence of the GP would I have expected [the General Surgeon] to have made a further appointment…
The GP did follow up [on the medication prescribed by the General Surgeon] within two days and record[ed] its effectiveness.
No further contact was initiated or appointments made after this consultation. Similarly, the Consumer's family did not make further contact with the hospital or GP. The Consumer's daughter-in-law reported that they made a decision to take her to a larger city to seek medical treatment because they were concerned by the Consumer's continued vomiting and increasing weakness. In mid-November 1997, a family member's GP had her admitted to Hospital. A scan subsequently showed liver and stomach cancer and the Consumer died in the first week of December 1997.
The General Surgeon states:
The lack of evidence of local recurrence on biopsy and lack of response to the trial of medication would have led to further investigation including admission. However, I did not see [the Consumer] or hear from her GP after her endoscopy.
Code of Health and Disability Services Consumers' Rights
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
4) Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.
Opinion: No Breach, General Surgeon
In my opinion the General Surgeon did not breach Rights 4(2) or Right 4(4) of the Code of Health and Disability Services Consumers' Rights as follows:
In establishing a diagnosis, it is not unusual for a series of tests and examinations to be done over time before a firm conclusion can be made. In the Consumer's case where the gastroscopy results did not lead to a diagnosis of cancer the General Surgeon stated that the medication he prescribed was given on a trial basis. If it did not result in the abatement of her symptoms then more tests would have been done and a referral possibly made for a CT scan. The Consumer and her family needed to maintain contact with her GP so that the cause of her illness could be discovered and treated appropriately. The GP could then co-ordinate the Consumer's care with the Hospital specialists.
While it would have been ideal for the diagnosis to have been made without the Consumer having to leave her home town, it is not possible to determine the extent to which the Consumer suffered as a result of the delay in detecting the return of her cancer. However I have been advised that the delay is unlikely to have increased her life expectancy.
I accept my surgical advice in that the General Surgeon's actions were reasonable in the circumstances.
Opinion: Breach, Hospital
In my opinion the Hospital breached Right 4(4) of the Code of Health and Disability Services Consumers' Rights. The Hospital did not perform the barium meal within one week of receiving the referral according to their priority guidelines. The Hospital needed to respond more promptly to the Consumer's GP's request to perform this diagnostic test so that appropriate treatment could be implemented.
The Hospital is to provide a written apology for its breach of the Code to the complainant. The apology should be sent to this Office and will be forwarded to the complainant.
I recommend that the Hospital review their processes for prioritisation and delivery of urgent diagnostic referrals.