A New Zealand surgeon has been found in breach of the Code of Health and Disability Services Consumers' Rights for the delayed diagnosis of breast cancer in a woman who presented with a breast lump.
Health and Disability Commissioner Morag McDowell released a report into the incident on Monday examining the surgeon and DHB's part in the woman's care.
The report found the woman, who was in her 40s at the time, had been diagnosed and treated for breast cancer in 2013.
During a routine checkup at a public hospital in September 2018, she was found to have a breast lump and the breast and general surgeon performed a biopsy.
However, she failed to order a mammogram or an ultrasound which was contrary to the DHB's protocol for the investigation of breast lumps.
The surgeon then formed the opinion the breast lump was benign and the woman was discharged.
But over the next five months, the lump began to grow "rapidly" and the woman was referred by her GP back to the public hospital.
A radiologist performed a series of ultrasound-guided biopsies and sent samples for testing. This led to a diagnosis of breast cancer and ongoing treatment.
During the investigation, the woman told the Health and Disability Commissioner (HDC) she would like to see a better system in place for the assessment of breast lumps.
“I feel that considering my previous history any lump found should have warranted an ultrasound and biopsy," she said.
Both the DHB and the surgeon apologised for the care.
“We are truly very sorry about [the woman's] delayed diagnosis of breast cancer, and the impact that this has had on her and her family," the DHB said.
The surgeon said she was "deeply sorry" for the "failure".
"I apologise unreservedly for the additional distress this has caused [the woman]. As previously advised, I was reassured by the findings of the FNA, which supported my clinical impression that the changes were fibrocystic changes only. With the benefit of hindsight, I should have given further consideration as to whether an ultrasound was also indicated even though the FNA was reassuring."
McDowell said the surgeon had failed to request an ultrasound or a mammogram of the woman’s breast lump, which was policy.
She said the report "emphasises the importance of complying with DHB protocol and accepted practice when investigating breast lumps".
The Commissioner has recommended the surgeon conduct an audit of her previous 20 assessments of patients in relation to potential breast lumps and report to HDC on the results.
She was also asked to provide a written apology to the woman.
The DHB was found not to have been in breach of the Code but the Commissioner did make recommendations for improvement of staff training.
