Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

Introduction

1. This report is the opinion of Dr Vanessa Caldwell, Deputy Health and Disability Commissioner, and is made in accordance with the power delegated to her by the Commissioner.
   
   
2. The report discusses the care provided to Mr A by Health New Zealand|Te Whatu Ora (Health NZ) Capital, Coast and Hutt Valley[1] and Dr B in relation to a delayed diagnosis of rectal cancer. Sadly, Mr A passed away in 2024.
   
   
3. The following issues were identified for investigation:

• • Whether Health New Zealand Capital, Coast and Hutt Valley provided [Mr A] with an appropriate standard of care between 4 August 2016–18 November 2020 (inclusive).

• • Whether [Dr B] provided [Mr A] with an appropriate standard of care on 18 November 2020.

4. The parties directly involved in the investigation were:

Dr B                                                                Medical officer/provider

Dr C                                                                Medical officer/provider

Mrs D                                                             Complainant/consumer’s mother

Health NZ Capital, Coast and Hutt Valley      Provider

5. Other aspects of Mrs D’s complaint about additional providers involved in Mr A’s care have been dealt with separately.
   
   
6. Independent advice was obtained from Professor Ian Bissett, a consultant general and colorectal surgeon and professor at the University of Auckland, Department of Surgery (Appendix A) and from medical officer Dr Stephen Adams (Appendix B).

Background

7. In 2016 Mr A (aged 39 years) was referred to a public hospital with a history of rectal bleeding. He was diagnosed with haemorrhoids and received banding. A further referral was made in 2017, and Mr A underwent a haemorrhoidectomy[2] on 28 September 2017.
   
   
8. Mr A attended appointments at a medical centre in May and November 2020 for ongoing abdominal pain and diarrhoea. No further investigations were undertaken at this time, and on both occasions Mr A was encouraged to enrol with a GP for follow-up.[3] Subsequently Mr A was diagnosed with advanced rectal cancer in January 2021, and he passed away in 2024.

Responses to provisional opinion

Mr A’s family

9. Mrs D was provided with an opportunity to comment on the ‘information gathered’ section of the provisional opinion. She said that the family were pleased to see the improvements that had been made as a result of what happened to Mr A. Mrs D stated that Mr A had to file for bankruptcy in the years before his diagnosis, which put stress on his home life on top of dealing with his illness.

Dr C

10. Dr C was provided with an opportunity to comment on the provisional opinion as it related to him. Dr C told HDC that he accepts the comments in the report and subsequent learnings and has no further comment to make.

Dr B

11. Dr B was provided with an opportunity to comment on the provisional opinion as it related to her. She advised that she had no comments to make.

Health NZ

12. Health NZ was provided with an opportunity to comment on the provisional opinion. Its comments have been incorporated throughout the report where relevant.

Opinion: Health NZ Capital, Coast and Hutt Valley — breach

13. I take this opportunity to extend my sincere condolences to Mr A’s whānau for their loss. I consider that deficiencies in the care provided by Health NZ Capital, Coast and Hutt Valley contributed to the delay in Mr A’s diagnosis. I have set out the reasoning for my decision below, and I have addressed the care provided in chronological order, starting with the care provided at Public Hospital 1 and Public Hospital 2 in 2016 and 2017 before addressing the care provided by Dr C and Dr B and the medical centre in May and November 2020.

4 August 2016

14. Following referral to Public Hospital 1, Mr A underwent haemorrhoid banding on 4 August 2016. Mr A’s history of rectal bleeding was documented, along with the possibility of a palpable mass. A sigmoidoscopy[4] was not performed at this consultation.
    
    
15. Professor Bissett advised that a sigmoidoscopy would be an essential part of a patient assessment even when a prolapsing haemorrhoid is identified. The possibility of a rectal mass was also included in the reason for referral/differential section of the referral document, and Professor Bissett considers that in these circumstances, the failure to perform a sigmoidoscopy was at least a moderate departure from expected practice.

28 September 2017 & 8 November 2017

16. Mr A attended a further consultation at Public Hospital 2 on 28 September 2017 due to ongoing rectal bleeding and occasional spontaneous blood loss, and subsequently he was scheduled for a haemorrhoidectomy on 8 November 2017 at Public Hospital 1. A sigmoidoscopy was not performed on either of these occasions.
    
    
17. Professor Bissett considers that a sigmoidoscopy would be standard practice in the context of the second referral, given that it had been a year since the banding and there was evidence that the initial management of the haemorrhoids had not given any material improvement in Mr A’s symptoms. Professor Bissett advised that not performing a sigmoidoscopy in these circumstances was a moderate departure from the accepted standard of care.
    
    
18. I accept this advice. While I acknowledge Professor Bissett’s comment that it is speculative as to whether a sigmoidoscopy performed at any of these opportunities would have changed Mr A’s clinical management, I am concerned that there were several missed opportunities at which a sigmoidoscopy was clinically indicated but not performed. I accept that multiple individuals were involved with Mr A over this time and, in my view, the responsibility for the deficiencies in care lay with Health NZ.
    
    
19. Accordingly, I find that Health NZ breached Right 4(1)[5] of the Code of Health and Disability Services Consumers’ Rights (the Code) as multiple staff failed to perform a sigmoidoscopy at the consultations in 2016 and 2017.

Dr C — educative comment

20. Mr A attended one appointment with Dr C on 1 May 2020. Mr A’s symptoms included abdominal pain and diarrhoea. Dr C’s documented diagnosis was irritable bowel syndrome[6] (IBS). Dr C told HDC that his differential diagnosis was coeliac disease,[7] and he accepts that this should have been documented. Dr C considered that a stool sample was not appropriate given that the source of Mr A’s diarrhoea appeared to be food related, and an FOBT[8] is not indicated in an acute setting, as per the bpac^nz guidelines. 

21. Independent advisor Dr Adams (Appendix B) raised two issues with the care provided by Dr C. First, Dr Adams advised that the single diagnosis of IBS considered by Dr C is a diagnosis of exclusion, which should be arrived at only after other possibilities have been explored.
    Dr Adams considered this to be a moderate departure from accepted practice but acknowledged that there were potential mitigating factors (discussed below) that might alter this finding.
    
    
22. Secondly, Dr Adams considered that a stool sample should have been taken. He advised that this is not a test for malignancy, it is a basic step in the diagnostic process for diarrhoea, particularly where it had lasted for over seven days, and he considered that this constituted a moderate departure from the expected standard of care, regardless of the final outcome. I note that Dr C considered that an FOBT was not appropriate in this case, but I am guided by Dr Adams, who advised that microscopic examination of a faecal sample was appropriate as opposed to an FOBT.
    
    
23. Dr Adams considers that both the departures identified were mitigated because of the medical centre’s policy on blood testing, which discouraged further investigations (unless relevant to immediate management), and because Mr A was given clear advice to follow up with a GP.
    
    
24. I accept this advice. I note that Dr C did document that Mr A was told to follow up with a GP, and I consider that Dr C was limited in the further investigations that could be arranged given the medical centre’s policies at the time. I consider that these mitigating factors reduce the severity of the departures from accepted practice. I note that Dr C has reflected on the standard of care provided, and I have no further recommendations.

Dr B — adverse comment

25. Mr A attended a second appointment at the medical centre on 18 November 2020 due to ongoing abdominal pain and diarrhoea and was seen by Dr B. Dr B did not examine Mr A but prescribed a short course of codeine and again advised him to enrol with a GP for follow-up. Dr B told HDC that this course of action was agreed with Mr A, although there is no documentation of this mutual agreement to defer care. 

26. Dr Adams advised that given that it had been six months since Mr A’s last consultation and Mr A was still having diarrhoea, which had not been diagnosed or investigated, Dr B should have examined Mr A and considered differential diagnoses, as the findings since his last consultation might have changed. Dr Adams concluded that this omission would be regarded as a moderate to severe departure from the standard of care.
    
    
27. I accept this advice. I note that Health NZ agrees that Dr B should have examined Mr A and documented a differential diagnosis, as set out in the medical centre’s ‘Orientation for Doctors’ guideline.[9] I am concerned that this did not occur, particularly given that Mr A’s symptoms had not improved, and he had not enrolled with a GP. However, noting the context in which Mr A was seeking care, via a medical centre, it is clear that the scope for follow-up was limited, and policies at the time reflected the expectation that a GP would be following up and making these diagnoses appropriately. Dr B appropriately advised Mr A of this limitation and the importance of enrolling with a GP in order to receive the test results for follow-up. Dr B sought agreement that Mr A would enrol with a GP to facilitate this process, and for this reason I do not find that Dr B breached the Code.   

The medical centre — educative comment

28. At the time of these events, the medical centre had in place a blood test policy (Appendix C) along with the centre’s ‘Orientation for Doctors’ document. The policy on blood testing sets out that laboratory or radiological tests are to be requested only for immediate management, while blood tests can be requested in certain circumstances.
    
    
29. Dr Adams advised that while it is reasonable for a medical centre to discourage long programmes of investigation, which should be managed by a patient’s GP or appropriate specialist, it is reasonable for a centre to instigate early tests such as urine and faecal samples and baseline blood tests and pass the results and patient to a definitive investigator. In this case, the medical centre’s policy defines tests as ‘urgent’ or ‘non-urgent’ and requires patients with urgent tests and non-enrolled patients with non-urgent tests to stay in the centre until results are available. Dr Adams advised that due to the practical difficulties (space in the waiting room, proximity to closing time, results not available the same day), this dissuades investigations and reduces the need for the centre to engage in follow-up and may cause the loss of an opportunity to make an early diagnosis.
    
    
30. In response to the provisional opinion, Health NZ told HDC that it accepts the comments regarding the approach to investigations at the medical centre, and changes have since been made to address these issues, as set out below.
    
    
31. I accept that there are difficulties with following up results for patients at a medical centre, as noted by the centre. However, I accept Dr Adams’ advice that the medical centre has a responsibility to instigate some tests based on the clinical picture, and therefore the centre needs a system in place to ensure follow-up, particularly in the context of patients with no GP. I note that the centre has since made changes (discussed below) to address these issues, and I am satisfied that the steps taken by the centre are appropriate.

Changes made since events

32. Dr C told HDC that he will take extra precautions with such presentations, and he now gives consideration to whether a DRE[10] may help to detect a potential mass that may represent malignancy. Dr C now ensures that he communicates and documents concerns about potential underlying and more serious conditions that would support strong advice to enrol with a GP.
    
    
33. In relation to the medical centre, Health NZ Capital, Coast and Hutt Valley told HDC that as a result of this case there has been a change of practice at the centre whereby doctors and nurse practitioners now have a lower threshold for commencing investigations in patients with chronic symptoms, particularly those without a GP and in cases where serious pathology is considered. The following changes have also been made:

• • Written information has been developed to provide to patients who attend the medical centre. The information includes the importance of enrolling with a local GP, and a list of local primary health organisations. There has also been discussion with the community care teams about other strategies to support unenrolled  patients to enroll with a GP.
    
    
  • The medical centre’s senior medical staff will review the policy on investigations, update it accordingly, and communicate this to the centre’s staff.
    
    
  • The medical centre’s flow diagram was updated to include additional forms of communication such as email and text message for abnormal test result follow-up.

34. In response to the provisional opinion, Health NZ Capital, Coast and Hutt Valley told HDC that the blood testing policy has since been updated at the centre. The key updates include the following:

• • Changes have been made to the wording to reflect that clinicians have a lower threshold to investigate if there is a serious concern about a patient’s presentation;
    
    
  • Follow-up on the results procedure has been changed to primarily involve text messaging or a phone call or contacting next of kin with post or email used as a last resort; and
    
    
  • The blood testing policy has been updated to reiterate that routine blood screening tests are not appropriate in an urgent care setting (as opposed to stating that all non-urgent blood testing is not appropriate in urgent care).

35. A guideline has also been implemented at the medical centre, ‘Unenrolled patients presenting to [the centre]’, which includes clinical guidance regarding investigations for patients who are not enrolled with a GP where there is concern about significant pathology.
    
    
36. In relation to general surgery, Health NZ Capital, Coast and Hutt Valley told HDC that the following changes have been made:

• • A rectal bleeding clinic has been established, which is led by a nurse practitioner.
    
    
  • All patients over 50 years, where either the GP or the triaging surgeon suspects that rectal bleeding is unlikely to be of anal origin, are now referred directly for a colonoscopy. Patients under 50 years are assessed initially in an outpatient clinic.
    
    
  • Management for patients presenting to outpatient clinics with rectal bleeding has been updated. All such patients now undergo a sigmoidoscopy as part of their evaluation, either a rigid sigmoidoscopy in clinic or at the time of the operation if the former was not diagnostic, or a flexible sigmoidoscopy or colonoscopy arranged from the outpatient clinic.

Recommendations

37. Noting the improvements already made, I recommend that Health NZ Capital, Coast and Hutt Valley provide a written apology to Mr A’s family for the deficiencies identified in this report relating to the care provided in 2016 and 2017. The apology is to be sent to HDC within three weeks of the date of this report, for forwarding to Mrs D.

Follow-up action

38. A copy of this report with details identifying the parties removed, except Health NZ Capital, Coast and Hutt Valley and the independent advisors on this case, will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

Appendix A: Independent clinical advice to Commissioner

The following independent advice was obtained from Professor Ian Bissett:

‘I am Ian Peter Bissett, a consultant general and colorectal surgeon at Auckland City Hospital. I am also a professor of the University of Auckland, Department of Surgery. I am vocationally registered with the New Zealand Medical Council and have medical qualifications of MBChB, MD, FRACS. I have also completed post fellowship subspecialty training in colorectal surgery and am a previous president of the Colorectal Surgery Society of Australia and New Zealand.

I have been asked to provide an opinion to the Commissioner on case number C22HDC02347. I have read and agree to abide by the HDC guidelines for independent advisors. I have been specifically requested to review the provided documentation and advise whether I consider the care provided to [Mr A] at [Public Hospital 1] was reasonable in the circumstances, and why.

“In particular, please comment on:

1.    Whether it would be expected for a sigmoidoscopy to be undertaken as part of [Public Hospital 1’s] assessment of [Mr A] in light of his history and GP referrals. Whether the absence of this procedure represents a departure from accepted practice; and

2.    Any other matters in this case that you consider warrant comment.

For each question, please advise:

a.    What is the standard of care/accepted practice?

b.    If there has been a departure from the standard of care or accepted practice, how significant a departure (mild, moderate, or severe) do you consider this to be?

c.     How would it be viewed by your peers?

d.    Recommendations for improvement that may help to prevent a similar occurrence in future.”

The following documents were provided to me and specify the material available to me upon which I provide my opinion:

1. Letter of complaint dated 20 September 2022;

2. Te Whatu Ora Capital, Coast and Hutt Valley’s response dated 12 December 2022; and

3. Clinical records from [Public Hospital 1] covering the period of June to November 2017.

Sequence of Events covering the time related to this advice.

[Mr A] was first referred to CCDHB by …  on 20 June 2016. The presenting complaint was stated as “PR blood, PR mass, unexplained weight loss and intermittent bowel prolapse.” His rectal bleeding was stated as having been occurring frequently over the previous 12 months and was at times associated with prolapse of his anal canal. The referral notes that on examination there was “a palpable mass at the end of reach ?polyp, also blood stained stool and the prostate was small and normal”.

On 4 August 2016 [Mr A] was seen in [Public Hospital 1’s] general surgical clinic and the letter states “on rectal examination there were no external abnormalities and on proctoscopy he has haemorrhoids, one at the 11 o’clock position and one is quite large and prolapsing and angry.” The registrar … who initially saw him called the consultant surgeon … who performed banding of his haemorrhoids. He was given pain relief and advised to return to his GP. He was informed that if his symptoms returned he should be referred back by his GP and he would be further reviewed.

[Mr A] was referred again to [Public Hospital 1] on 8 June 2017 by … with “worsening problems with haemorrhoids following banding last August ? (needing) haemorrhoidectomy.” “C/O ongoing problems with haemorrhoids since appt in August 2016 — requesting referral back to hospital as per [the registrar].”

[Mr A] was seen in outpatients in [Public Hospital 2] by  … General Surgical Registrar, on 28 September 2017. She noted that “He was seen a year ago in [the consultant sugeon’s] clinic at which time a haemorrhoid was seen and banded. He reports that the improvement from the banding only lasted for three days and then he went back to have daily bleeding.” She stated that “On examination he has a large grade 3 external haemorrhoid at the 9 o’clock position that is reducible. It is friable and bleeding.” He was booked for an open haemorrhoidectomy. There is no mention of sigmoidoscopy in the letter. His haemoglobin was noted to be normal at 140 g/L.

On 8 November 2017 [another consultant surgeon], performed a Ligasure open haemorrhoidectomy. During the procedure a digital rectal examination is described and the insertion of a haemorrhoid retractor. A three pedicle haemorrhoidectomy using the Ligasure was performed. There is no mention of a sigmoidoscopy being undertaken during this procedure.

[Mr A] was discharged the following day with the plan for follow up in 6 weeks. It is stated that [Mr A] did not attend his follow up. The subsequent histology report of the haemorrhoid specimens confirmed haemorrhoids only.

According to the patient complaint a diagnosis of advanced rectal cancer was made at colonoscopy in January 2021.

Opinion

In response to the questions of the commissioner

1. Whether it would be expected for a sigmoidoscopy to be undertaken as part of [Public Hospital 1’s] assessment of [Mr A] in light of his history and GP referrals. Whether the absence of this procedure represents a departure from accepted practice;

In the setting of the GP referral of 2016, where the referring GP had specifically stated that there was a possible mass at the tip of reach on digital examination, the performance of a sigmoidoscopy would be an essential part of the patient assessment even when a prolapsing haemorrhoid is identified. The possibility of a rectal mass was also included in the reason for referral/differential section of the referral document. I would consider this to be at least a moderate departure from the expected practice and I am sure that this view would be shared by my peers.

In the setting of the second referral, more than a year after the banding with evidence that the initial management of the haemorrhoids had not given any material improvement in the patient’s symptoms, I would again consider the performance of a sigmoidoscopy standard practice. This could have occurred at the outpatient assessment or during the operative procedure for the haemorrhoids. As far as I can identify from the documentation of these encounters with the patient, a sigmoidoscopy did not occur at either. This also would be a moderate departure from standard care. I have taken the opinion of another general surgical consultant, who also considered a sigmoidoscopy to be part of the expected standard of care in assessing such a patient.

2. Any other matters in this case that you consider warrant comment.

In reviewing this patient’s journey I have the benefit of hindsight and this does influence the perspective that I have brought. It is certainly possible that on the first outpatient appointment the consultant who was called to do the banding was not aware of the possible rectal mass mentioned in the referral. In the second outpatient clinic assessment it is possible that the registrar who saw [Mr A] expected the sigmoidoscopy to be performed at the time of the haemorrhoidectomy, but this was not recorded in the [centre’s] letter. It is also likely that the initial referral from 2016 that mentioned a possible rectal mass was not viewed during the second outpatient visit in 2017, as it would be usual practice to review the previous outpatient letter rather than the earlier referrals at this point.

The fact that the patient did not return to outpatients for review after the haemorrhoidectomy meant that the possibility for earlier identification of ongoing symptoms was lost. The identification of continued symptoms would have triggered further investigations to identify the cause. The reason for the failure of follow up is not clear but another follow up process that included telephone contact may have been more successful.

Finally, I recognise that it would be speculative to comment on whether a sigmoidoscopy performed at any of these opportunities would have changed management but it could have. Although the rectal cancer is likely to have been present at those times it could also have developed between 2017 and 2021.

I acknowledge that this has been a very distressing situation for [Mr A] and has significantly impacted his physical ability and quality of life. I also appreciate that those who cared for [Mr A] will be disturbed that this sequence of events has occurred.

Yours faithfully,

Professor Ian Bissett’