Missed opportunities in cancer patient care

Deputy Health and Disability Commissioner Vanessa Caldwell today released a report finding the Southern District Health Board (SDHB) and a general surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for missed opportunities to diagnose a man with colon cancer.

A man in his fifties had a history of schizophrenia and chronic thought disorder, and lived in a community residential mental health service. Over a six week period he presented to the Emergency Department seven times with severe abdominal pain. He was repeatedly diagnosed as having constipation as a result of an anti-psychotic medication (lithium).

At each presentation the man’s diagnosis remained the same, despite lack of improvement and other red flags indicating something else may be causing his pain. Each staff member failed to question the previous diagnosis or undertake further investigations until he underwent surgery to examine the abdomen.

During the surgery the man was found to have widespread colon cancer with tumours causing a complete obstruction of the bowel. Sadly the man died of septic shock, secondary to metastatic colon cancer.

The Deputy Commissioner considered that there were numerous missed opportunities by many SDHB clinicians, across multiple presentations, to investigate the man’s symptoms further and reconsider his diagnosis when he failed to improve.

“The cumulative effect of these missed opportunities demonstrates a concerning lack of critical thinking and acceptance of the man’s unimproved condition by SDHB staff, attributable to the DHB as the overall service provider, said Dr Caldwell.

“I acknowledge that the man’s illness was metastatic, and that an earlier diagnosis many not have influenced the ultimate outcome. However, I note that an earlier diagnosis of colon cancer could have opened up opportunities for palliative care that could have led to a significantly different end to this man’s life.”

Dr Caldwell recommended that SDHB provide HDC with any protocols or procedures that have been developed as a result of meetings it has since had with mental health care providers from the community. She also asked that SDHB provide evidence of relevant staff training and orientation to these new protocols and procedures. She recommended that an anonymised case study of this case be presented to all emergency department and general surgery staff at the public hospital for educational purposes, implement a new policy/procedure about the use of CT scans in ED, and consider how the DHB can improve the continuity of care in situations where a patient presents to hospital multiple times.