A lack of communication and record-keeping between medical staff contributed to a man dying from a cancerous melanoma that went undiagnosed during multiple examinations.
The 65-year-old man was having a checkup at a public hospital three months after undergoing a first stage hip joint revision when a nurse noticed he had a large bleeding lesion on his back.
She treated it and advised the man to have checked by his orthopaedic surgeon at an upcoming consultation but did not record the conversation nor was there a record that the examination took place.
There was also no formal request for a medical review or any follow-up action by the nurse.
When the nurse saw the man again the lesion had flattened and stopped bleeding but again she did did not record a discussion she said she had with the man about his consultation with the surgeon.
When he was admitted to hospital for the second stage of his hip joint revision, a hospital nurse recorded the bleeding mole on his back but there was no documentation of any observation, monitoring, or initiation of a medical review of the lesion.
The man eventually asked a hospital doctor about the lesion who referred him for excision where it was found to be a malignant melanoma.
He died as a result of the skin cancer.
Health and Disability Commissioner Anthony Hill found the two nurses breached their duty of care of the man, particularly the rural nurse who relied on the man to bring up lesion instead of writing a referral.
Mr Hill also was critical that conversations regarding the mole were not recorded.
Both nurses have apologised to the man's family.