A woman in her 60s had been losing weight and had bowel symptoms when a gastroenterologist spotted a “pelvic mass” on her uterus, following a CT colonography.

But a failure in Health New Zealand Te Whatu Ora‘s referral system meant the mass wasn’t examined further by ultrasound, and went undiagnosed, for six months.

The woman, named as Ms A in a finding released today, only received an ultrasound after her symptoms had worsened and she presented to hospital. She was found to have advanced ovarian cancer and died some months later.

Her family complained to the Health and Disability Commission stating they believed Ms A’s terminal cancer could have been prevented.

“There appears to be a failure in the referral system, along with us not knowing better about the aggressive nature and severity of gynaecological cancers since no one receives education or awareness on this ...” the family said in its complaint.

“If the referral was actioned when it should have [been], I believe we could have saved my mum’s life. We’re providing this feedback in hopes that this does not happen to another family again.”

The HDC found Health New Zealand Te Whatu Ora Te Toka Tumai Auckland had a systems failure, where a referral made by the woman’s GP did not get entered into the appropriate database.

There was no electronic interface between the Referral Management System (RMS), where the GP’s e-referral arrived, and the Radiology Information System (RIS), which would have triggered an ultrasound appointment.

At the time of events, the process involved a referral being printed by one staff member, and entered and scanned by another staff member.

Health NZ acknowledged those staff carried out other reception and administration duties at the same time, and “there was no reconciliation process in place to check that the referrals that had been received in RMS had been loaded into RIS”.

HDC Deputy Commissioner Vanessa Caldwell said the case demonstrated a “critical systems issue” at Health NZ.

“[Health NZ] failed to implement adequate measures to prevent patient harm caused by the lack of systems integration ... it did not recognise the clinical risk created by the lack of support provided to new staff.”

The HDC said Health NZ had been aware of the “systems limitation” and had “acknowledged there was no safety-net in place”.

It was “regrettable” that the data entry error made by the booking and reception administration led to “a significant delay in the provision of care to Ms A”, the HDC found.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell.

After the consultant gastroenterologist spotted the right-sided pelvic mass, which appeared solid, lobulated and separate from the uterus, he asked Ms A’s GP to make referrals for a pelvic ultrasound and a gynaecological appointment.

The GP, referred to as Dr B in the HDC findings, made those two referrals, via an electronic process, with both forms labelled “urgent”, and noting the incidental finding of the mass.

Dr B did receive an email from gynaecology, requesting Ms A undergo blood tests for biomarkers, as there was “insufficient information to triage the referral”.

However, Dr B did not request the additional tumour markers as he believed it would be “redundant” and “unnecessary”. He was under a “reasonable impression” that Ms A would qualify for an urgent gynaecology clinic appointment, based on the existing findings, including the large mass.

His failure to complete the additional requested tumour markers constituted “a mild departure” from the accepted standard of practice, the HDC found, given those markers had a limited role in the diagnosis of ovarian malignancy.

Although Dr B explained his clinical reasoning for his decision, Dr Caldwell was critical that he did not seek clarification when he was unwilling to order the additional tests.

When the woman visited on an unrelated matter a couple of months later, he asked his receptionist to clarify the wait time for the ultrasound scan.

“Dr B said that they were not given any specific indication other than a ‘long wait’, and the radiology staff did not give any indication that the referral was not in their system,” the findings said.

After two weeks of abdominal bloating and pain, four weeks of constipation, and two days of vomiting, Ms A was referred to hospital where it was found the pelvic mass had progressed in size, and she was diagnosed with advanced ovarian cancer.

Ms A wanted to travel to China to see her parents and receive treatment, however, she wasn’t cleared to fly given the “risk of a sudden event leading to her death” and a life expectancy that was “limited to weeks to months”.

The tumour did not respond to chemotherapy, surgery wasn’t an option due to the progression of the cancer, and Ms A passed away a month after entering end-of-life care.

The HDC found the GP’s management of the referral also “constituted a mild departure from the accepted standard of practice”.

“... it is important for primary-care providers to track referrals to secondary care and provide updated referral information when relevant, to ensure that management is undertaken in a timely manner,” the findings stated.

It was noted that it was “unclear whether [formal] tracking would have altered Ms A’s outcome”, given the scheduling of the first gynaecology specialist appointment was dependent on receipt of the ultrasound referral.

Advice to the HDC said Ms A’s delayed diagnosis was due to process failures and inefficiencies in secondary care, as opposed to an oversight by Dr B.

However, Dr Caldwell reminded Dr B that as the access point to secondary care, GPs should follow up referrals and ensure that appropriate action has been taken.

She encouraged him to act proactively and with a degree of urgency when managing patient referrals, particularly when a life-threatening disease is involved.

Both Dr B and Health NZ apologised to the family of Ms A.

Health NZ is making ongoing changes to integration between systems, and there are now weekly reports that allow for cross-referencing to ensure referrals have been entered.

There are dedicated booking clerks for primary care referral, who do not have the additional responsibility of working reception, and do the task at a dedicated time where there are minimal distractions.

Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.