A man has died from rectal cancer after miscommunication between his GP and a district health board resulted in him waiting for months for specialist treatment.
The man first visited his doctor complaining of weight loss and rectal bleeding, which was partly diagnosed as irritable bowel syndrome and carcinoma, leading to the GP referring him to the local gastroenterology department.
But the referral was never received by the DHB, and the GP did not set a reminder to follow it up.
The man visited the Emergency Department with groin swelling a few days later, where he was referred to the general surgical team with a suspected inguinal hernia.
When the second referral was denied, the GP incorrectly believed it was related to the initial referral.
The man returned to his local medical practice two months later, still suffering from the bowel symptoms where a locum GP discovered the first referral had not been received by the DHB, and sent another but allocated it a lower priority of around six weeks wait time.
Five weeks later, the man visited his local doctor again, continuing to display bowel symptoms, and the doctor decided to wait until the gastroenterology review to provide further treatment.
No review appointment was made and one month later the man returned to the emergency department with blood in his urine.
Tests revealed his rectal cancer had advanced and he later died in hospice care.
Health and Disability Commissioner Anthony Hill criticised the GP, saying he misclassified his initial referral as not urgent, did not provide advice on what the man should do if his symptoms continued and did not schedule a follow-up to his referral.
He found the DHB's delays in processing the GP referrals were also substandard and criticised them for not providing clear information on when the man would receive specialist care.
The doctor and the DHB both apologised to the man's family while the HDC recommended an audit of the GP's referrals to check that appropriate requests have been made and appropriate reminders have been put in place to follow up such referrals.