A man with widespread colon cancer has died after repeatedly being told he just had constipation.
The patient turned up to an emergency department seven times in six weeks with severe abdominal pain, but Southern DHB (SDHB) staff failed to reconsider an earlier diagnosis and he later died.
The man in his 50s had a history of schizophrenia and chronic thought disorder and lived in a community residential mental health service.
Southern DHB staff repeatedly diagnosed him with having constipation as a result of antipsychotic medication.
Even with the 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 his abdomen.
The surgery found the man had widespread colon cancer with tumours causing complete obstruction of the bowel.
The man died of septic shock, secondary to metastatic colon cancer.
A report released by Deputy Health and Disability Commissioner (HDC) Vanessa Caldwell into the incident on Monday said there were missed opportunities in multiple presentations to investigate the man's symptoms further.
The health board and the surgeon were found to be in breach of the Code of Health and Disability Services Consumers' Rights.
"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," Dr Caldwell said.
"I acknowledge that the man's illness was metastatic, and that an earlier diagnosis may 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."
Southern DHB chief executive Chris Fleming said the board accepted the findings of the HDC complaint.
He said they wanted to wish their sincere condolences to those who knew the patient and said they had reflected on the care provided and accepted that it should have been of a higher standard.
He said Southern DHB has taken steps to ensure a situation like this does not occur again.