A woman who was called and told she needed an urgent colonoscopy but wasn’t told why duly showed up and underwent the invasive procedure, before learning she was mistaken for another patient and didn’t actually need it at all.

The Auckland woman, who had already undergone an initial colonoscopy, had her National Health Index (NHI) number confused with another patient when she was called in for a second one according to a decision by the deputy Health and Disability Commissioner released today.

The woman required five-yearly surveillance colonoscopies for an existing health issue. She underwent the procedure in Counties Manukau and four polyps were removed. The date of the procedure is not detailed.

Two days later she received a call from the colonoscopy clinic, advising that a specialist had referred her for another urgent colonoscopy. The patient attempted to phone the specialist to understand why, but he never called her back.

She showed up to the appointment, asking the nurse why the procedure was required. The nurse didn’t know, and didn’t record the woman’s query in her clinical notes.

The procedure went ahead. It was only while it was taking place that a different specialist noted the findings on the referral form were not consistent with what he was seeing in real-time.

This specialist contacted the referring specialist, and the pair discovered there had been an accidental mix-up of NHI numbers.

The woman was told of the mistake after her sedation had worn off. She later received a verbal apology from the referring specialist, and a letter from Te Whatu Ora advising an adverse event review would be undertaken.

That review found the referring specialist accidentally attached the wrong NHI number to an email. The woman’s calls should have sparked administrative staff to spot the error.

Deputy commissioner Dr Vanessa Caldwell concluded Te Whatu Ora breached the code of consumer rights.

She adopted the recommendations of the adverse event review, which included attaching support reports to emails, having a clear process when a patient queries a referral and to check previous results or reports before a procedure.

Te Whatu Ora confirmed to Caldwell that it has complied with the recommendations.

Ethan Griffiths covers crime and justice stories nationwide for Open Justice. He joined NZME in 2020, previously working as a regional reporter in Whanganui and South Taranaki.