Five years of bleeding, nine appointments, three different hospitals , five different consultants and zero scans have resulted in one tragic outcome for a Northland whānau - the death of a mother diagnosed with stage four cancer that was too late to cure. Now, the Health and Disability Commissioner has held Te Whatu Ora Te Tai Tokerau directly responsible for breaching the woman’s rights citing systemic failures that resulted in missed opportunities for timely intervention. “The missed opportunities to provide this information are attributable to multiple clinicians, and signify a failure at an organisational level, for which Te Whatu Ora Te Tai Tokerau is responsible,” Deputy Commissioner Dr Vanessa Caldwell said in a decision released today.
“At the outset, I offer my sincere condolences to Mrs A’s whānau for their loss. I acknowledge that this matter continues to cause them significant distress, and I thank them for bringing their complaint to this office.” The saga began in 1999 when an ultrasound revealed a large fibroid in Mrs A’s uterus which was left with no follow-up.
In July 2014, after experiencing post-menopausal bleeding Mrs A, a woman in her 50s who lived in rural Northland but was not named in the decision, was referred to Te Whatu Ora Te Tai Tokerau (TWOTTT) Gynaecology Department in Whangārei. Despite a series of polyp tests indicating no malignancy no imagery tests were performed and Dr F concluded by writing to Mrs A that she see her GP .
