A woman who went to her doctor with deteriorating symptoms didn’t have her vital signs checked and died a few weeks later from esophageal cancer that went undetected.
The woman, aged in her 60s, attended two different doctors, weeks apart, at an unnamed medical centre in New Zealand.
She presented with symptoms that included fatigue, loss of appetite, weight loss and feeling cold.
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Her cancer was only detected when she attended an emergency room and was unable to swallow liquids.
Following her death, the Health and Disability Commissioner launched an investigation, which found the second doctor she saw was in breach of the Code of Health & Disability Services Consumers’ Rights.
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In a decision published on Monday, the first doctor the woman saw ordered blood tests for a general initial investigation and made a request to for an ultrasound scan of the woman’s liver.
A letter from the radiology department at the public hospital that the request was made to told the doctor the wait time for an ultrasound was 30 to 38 weeks.
The woman visited the same medical centre weeks later, with deteriorating symptoms, and saw a different doctor.
“The second doctor did not perform a physical examination or record any vital signs,” the decision said.
The second doctor prescribed the woman medication for thyroid hormone deficiency and indigestion and planned to review her again in four to six weeks’ time and repeat blood tests.
The second doctor told the commissioner he recalled advising the woman she should be admitted to hospital that day, but she refused because it was a public holiday.
The woman’s husband, who attended the appointment with her, said he doesn’t recall that advice.
Five days later, the woman attended an emergency department as her condition worsened and she was unable to swallow liquids.
She was diagnosed with metastatic esophageal cancer and died a few weeks later.
Aged Care Commissioner Carolyn Cooper found the care provided by the second doctor fell below appropriate standards.
Cooper found the doctor breached the code, which gives consumers the right to have services provided with reasonable care and skill.
The commissioner recommended the second doctor provide the family with an apology.
She also recommended the medical centre implement a new management process for filing documents.
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