A decision released by the Health and Disability Commissioner yesterday said HNZ missed multiple opportunities to identify the tumour between the man’s first appointment with the ophthalmology service in April 2019, when he complained about a lack of vision in his right eye, and his appointments in July 2021, when he finally received radiation treatment.

The commissioner criticised HNZ Southern for the lack of communication between the ophthalmology and radiology departments throughout the man’s treatment.

‘‘I am satisfied that several opportunities existed for recognition that the referral to radiation oncology had not occurred, including contact with the neurosurgical team in April and July 2020, although a critical communication error also occurred after the first neuro-oncology multidisciplinary meeting [MDM].

‘‘In my view, failures at a systems level led to the breakdown in communication between services regarding the man’s need for radiotherapy, which ultimately led to a delay in referral and treatment … every consumer has the right to have services provided with reasonable care and skill, and the delays in this matter fell below the expected standard of care.’’

The commissioner said if the expected process had been followed, then after the Southern neuro-oncology multidisciplinary meeting on February 11, 2020, there would have been an MRI, after which the man would have been referred to radiation oncology for consideration of radiotherapy.

‘‘However, neither the MRI nor the referral occurred at that time, and, despite multiple opportunities to action referral to radiation oncology, this occurred only in February 2021, with treatment commencing in June 2021 — a referral delay of 12 months.’’

A neurosurgeon who externally assessed the case for the ACC found gaps in the treatment, and told the commissioner the failure to refer for consideration of further treatment at that time was an omission in the treatment pathway that had ‘‘resulted in a treatment injury and is below the standard of care’’.

HNZ Southern told the commissioner that it ‘‘sincerely apologise[d]’’ to the patient for the ‘‘significant system failure’’.

HNZ Southern said it had since instituted several changes as a way of improving inter-department communication. These include:

• Introducing MDM co-ordinators whose role includes the taking of the meeting minutes and then uploading decisions to a patient’s file.

• Creating a position in the oncology service for a nurse navigator who manages patients on the wait list who have yet to be seen at a first specialist appointment for the oncology service.

• Ensuring all post-operative notes from neurosurgery are now recorded electronically, including postoperative instructions.

There were other stated ‘‘improvements’’ that had not advanced further, such as the trialling of a neurosurgical clinical nurse specialist, due to a lack of funding, HNZ Southern said.

The commissioner has asked HNZ Southern to provide a written apology to the patient and the family.

matthew.littlewood@odt.co.nz

Original source: nz