Two District Health Boards have failed a woman whose fatal breast cancer was mistaken for an infection, despite two scans showing otherwise.
A report from the Health and Disability Commissioner Morag McDowell released on Monday found the Wairarapa and Hutt Valley health boards breached the Code, for failures that led to a two-month delay in diagnosing a woman with breast cancer.
In October 2018, the woman, who was in her 40s, saw her GP because of a painful lump in her breast. The doctors said it was likely breast cancer so the woman was fast-tracked as a suspected cancer patient and referred to the Wairarapa DHB (WDHB).
The woman's local DHB, WDHB, does not have a permanent breast specialist surgeon, so patients are referred to Hutt Valley District Health Board (HVDHB) for breast imaging and interventional procedures, ultimately leading to problems with diagnosing the woman's cancer.
The report found the woman contacted HVDHB three times within five days for an appointment but was refused on the basis that "it was just an infection".
Her condition worsened and she received an ultrasound and CT scan at WDHB, which showed a large mass on her breast that was suspected of being cancer.
The woman also underwent a biopsy at HVDHB which, unlike the scan and ultrasound, came back negative.
The woman's case was discussed at the Hutt Breast Multidisciplinary Meeting on November 12, 2018, where her ultrasound, scan and biopsy were reviewed.
The report said on the basis of the biopsy result they concluded that she did not have cancer.
She was instead diagnosed with plasma cell mastitis, which is a condition in which breast tissue is inflamed.
Following the biopsy she experienced problems with swelling, oozing and increased pain, prompting her to see her GP, the emergency department and specialist surgeons on numerous occasions over the next two months.
She ended up getting a second biopsy and it wasn't until January 9, 2019, when she got the result that she likely had inflammatory breast cancer.
She was initially told it was stage three and treatable, but a week later she was diagnosed with terminal stage four cancer.
The woman sadly passed away later in 2019.
The woman's husband told the Health and Disability Commissioner the system failed his wife in a major way, as the misdiagnosis contributed to her suffering.
"All faith that [name] and I had in our medical system disappeared very quickly. It felt that because [name's] case was a complicated one, no one wanted to know," he stated to the commission.
Health and Disability Commissioner was critical of HVDHB for diagnosing the woman with plasma cell mastitis, without questioning the biopsy result which did not accord with the imaging results.
"Due to multiple clinicians involved, the woman's care was affected by the lack of clarity as to which DHB and clinician had overall responsibility for her," McDowell said in a statement.
"Under the Code, consumers have the right to co-operation among providers to ensure quality and continuity of services, and therefore I have found that both DHBs are equally responsible for the delay in her diagnosis."
McDowell said it was encouraging to see that both DHBs have acknowledged the lack of clarity in their breast service and implemented changes to their processes such as a "red flag" system for abnormal results to improve it.
Both DHBs sent written apologies to the woman's husband.
