A man with colon cancer was undergoing his first round of chemotherapy when he became so unwell that he was rushed back to the private oncology clinic that was treating him for an assessment.

But after receiving IV fluids and anti-nausea medication, he was discharged and went home, where he collapsed and died that evening due to a cardiac event.

Now, following a complaint to the Health and Disability Commissioner from the man’s wife, the clinic Canopy Cancer Care has been found in breach of some aspects of its care of the patient.

Today, Deputy Health and Disability Commissioner Deborah James released the findings of her investigation, which described how the man, who was in his 40s and had been treated for a type of arrhythmia, or abnormal heartbeat, became unwell on day three of his first cycle of chemotherapy.

His treatment had begun at the clinic and then continued by infusion pump for 48 hours while he was at home.

But overnight, on the final day of the cycle, the man, who is not named in the report, became unwell, with symptoms including sweating, agitation, nausea and about eight episodes of vomiting.

His wife saw he was short of breath and phoned the clinic. She spoke with a general oncology nurse, who advised she bring her husband in so his nausea and vomiting could be managed.

An ECG conducted showed the man had a fast resting heart rate, a heart conduction disorder that could cause abnormal activation of the ventricles, and an ST elevation, which the decision stated was “an abnormal finding on an ECG”.

The nurse then administered the anti-nausea medication intravenously, before a medical assessment and without a prescription, and put him on a saline drip.

An oncologist, who that morning was “running a fully booked clinic”, reviewed the man and checked the observations made by the nurse and the ECG report.

Deputy Health and Disability Commissioner Deborah James investigated the complaint about the man's care.

He told the patient there were no symptoms of angina, and excluded a cardiac cause.

The oncologist retrospectively signed off the administered medication and ordered more saline. He told the Health and Disability Commissioner (HDC) he expected he would later conduct a further review, although he did not communicate that to the nurse.

He did not order blood tests and told the HDC as there was no indication the man was suffering from anything other than standard side-effects of chemotherapy, it was not a priority.

Soon after finishing a second bag of saline, the man was discharged.

His wife told the HDC her husband appeared confused but the nurse denied he was confused and said the man had “expressed a strong desire” to leave.

The nurse said she “expressly advised” him not to leave until he had been re-assessed, but his wife rejected they were ever informed about a re-assessment from the oncologist.

He left the clinic around midday and was later checked on by the nurse via a phone call, but no follow-up was made by the oncologist.

Later that day, he began to deteriorate and asked for an ambulance. While his wife was on the phone, he collapsed and died.

A post-mortem identified a right coronary artery anomaly that can cause reduced blood flow to the heart and sudden death during stress.

The man’s wife told the HDC he was not adequately informed of the fatal risk of chemotherapy treatment, including the potential for cardiotoxicity due to the chemotherapy drug.

She said that they were told angina might occur, and to expect vomiting and nausea, “neither of which are usually fatal to a patient”.

The report showed he had a normal ECG before he began chemotherapy treatment, which consisted of drugs with a risk of adverse cardiac effects.

Key life-threatening side effects of the treatment, including “angina or ‘heart pain’, which can lead to a heart attack”, were also discussed with him and further information was provided.

In her findings, James found the clinic was in several breaches of the Code of Health and Disability Services Consumers’ Rights, including its failure to give consumers the right to services provided with reasonable care and skill.

This breach concerned the lack of guidelines in place for the assessment and management, including timely blood screening, of chemotherapy patients who present to the clinic unwell.

“A heavy reliance on decision-making and co-ordination by individual clinicians, without the support of a formal strategy for the management of acute patients, led to gaps in the care provided,” James said.

The clinic also breached the man’s right to services that comply with legal, professional, ethical and other relevant standards related to the administration of IV prescription medicine, and it failed to have clear roles and responsibilities in place to enable accessible assessment and record-keeping tools to ensure continuity of care.

While the nurse was found in breach of the code by administering the IV prescription medicine to the man contrary to legislation, and for keeping inadequate records, James noted her actions appeared well-intentioned and had been affected by some systemic issues.

“[However], this decision reflects the important role of nurses in upholding individual practice standards despite challenging healthcare environments.”

The oncologist was found in breach of the code for not conducting timely blood testing and for retrospectively authorising a prescription for the IV medicine.

Since the man’s death, the clinic has identified gaps in its service and developed Management of Acute Patient Guidelines, the report stated.

However, she recommended the clinic, the nurse and the oncologist provide a written apology to the man’s family, and an audit of staff clinical records and clinical nurse educator training take place, as well as reviews of the clinic’s blood screening and referral processes and prescribing processes.

In response to the findings, the clinic told NZME it wished to extend its deepest condolences to the affected parties.

“Canopy Cancer Care acknowledges and accepts the findings and recommendations outlined in the Health and Disability Commissioner’s report.”

Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff where she covered crime and justice, arts and entertainment and Māori issues.