A doctor's clinical records are now being audited after failing to tell a 63-year-old woman that she had abnormal blood results, causing delays to her treatment.
It was not until three months after the results came in that the woman was visiting her daughter in another part of the country and still in pain that she was diagnosed with gallstone pancreatitis by a doctor at a different medical centre.
The woman first went to the doctor in May 2018 complaining of abdominal pain after eating, weight loss and a loss of appetite, according to a report by the Health and Disability Commissioner released today.
The doctor examined the woman and ordered blood tests. He also prescribed her with medication for indigestion and said he would follow up with her after a month.
But when the results came back and the liver function tests showed anomalies, he failed to contact her.
In the August that year, the woman's daughter took her to see a doctor at another medical centre when she was visiting her in another region and her pain was getting worse.
The doctor ordered more blood tests and this time told the woman's daughter the liver function tests were abnormal due to a likely obstruction in her biliary system.
On the same day they learnt of the results, the woman was in utter agony and vomiting so her family took her to the emergency department where she was diagnosed with gallstone pancreatitis. Nine days later she had a laparoscopic cholecystectomy.
The doctor told the HDC it was standard practice to telephone patients if there were urgent issues, and said he should have this time.
He gave a number of reasons for not calling, including that she was due in for a follow-up appointment three weeks later.
In his findings, Health and Disability Commissioner Anthony Hill found the doctor failed to provide the woman with services of reasonable care and skill by not telling her of the abnormal blood results, and organising an urgent ultrasound.
An audit of the doctor's clinical records was ordered by the HDC and he was also told to provide a written apology to the woman.