GP breaches code for not following up on ultrasound - 22HDC00760

In a report released today, the Health and Disability Commissioner has found a GP breached the Code of Health and Disability Services Consumers’ Rights (the Code) for not following up with a patient he had referred for an ultrasound.

The woman, in her sixties at the time, attended a consultation with her GP after experiencing post-menstrual bleeding. The GP documented that the woman had experienced some bleeding over the past few days that was not associated with any pain and provided her with a voucher for an ultrasound scan.

However, following the consultation the woman did not undergo the ultrasound scan, as she had the impression from the consultation that the bleeding was nothing to be concerned about and that the scan was optional. Approximately a year later, the woman developed accompanying abdominal pain, and, sadly, was diagnosed with stage 4 endometrial cancer.

In her report, Deputy Commissioner Deborah James accepted that the GP had followed the appropriate Community Health Pathway by advising the woman to undertake an ultrasound prior to undertaking any further investigation.

However, given this was to be self-initiated, Ms James was critical that, in light of the risk of endometrial cancer, the GP did not follow up with the woman to ensure she had undergone the scan. She found the GP did not provide the woman with service of an appropriate standard and was in breach of Right 4 of the Code which gives consumers the right to an appropriate standard of care | Tautikanga.

Ms James also made an adverse comment about the medical centre for deficiencies in its policies for tracking referrals made through the voucher system. Since the events, the centre has updated its process for the voucher system, which includes that a manual task reminder must be set every time a clinician refers a patient for an ultrasound scan.

Ms James recommended the GP provide an apology to the woman and undergo training in therapeutic communication with patients, should he return to practice.

She also recommended the medical centre undertake an audit of all voucher referrals to ensure that task reminders have been made by clinicians and develop an education session for staff using an anonymised version of the HDC report.