Deputy Health and Disability Commissioner Dr Vanessa Caldwell has found Te Whatu Ora - Waitaha Canterbury (formerly the Canterbury District Health Board) and an unnamed GP failed a woman in multiple areas, resulting in a delayed diagnosis of multiple sclerosis (MS).
In 2010 the woman was referred by her GP to the ophthalmology service at the public hospital after suddenly losing her vision.
The woman was diagnosed with demyelinating optic neuritis - inflammation of the optic nerve, which Dr Calwell said is often associated with MS.
A subsequent MRI confirmed the woman had optic neuritis, along with abnormal white matter lesions in the woman's brain - raising the chances of primary demyelination.
A year later, the woman was then referred to the neurology service where she would undergo further assessment, and was prioritised as "semi-urgent".
But with limitations on resources the woman's referral was denied and she was advised to remain under the care of her GP.
In 2015 she took herself to a GP at a new medical centre when tingling in her left arm and legs began, resulting in the woman falling over multiple times on different occasions.
The GP ordered screening tests to investigate a provisional diagnosis of a mini-stroke or an inflammatory disorder.
Dr Caldwell said the GP did not refer the woman for specialist assessment by a neurologist or ordered a management plan for follow-up advice or structured review of the woman's results.
Three years later, in 2018 the woman presented herself again at the same medical centre, this time seen by a different GP.
Dr Caldwell said the new GP's impression was that the woman had a migraine and inner-ear disorder causing vertigo. A couple of days passed and the woman called the medical centre as symptoms continued.
"Clinical records do not indicate whether the nurse who took the call discussed this with the GP, or what actions were taken to follow-up with the woman."
The woman was then referred urgently in 2019 to the neurology service by the medical centre after presenting to another GP.
That GP found clinical documentation from 2011 noting that the woman's MRI had shown features consistent with demyelination.
A couple of weeks follow and the woman was diagnosed with MS.
Dr Caldwell says the several-year ordeal caused "distress" to the woman, adding that the nine-year late diagnosis was a missed opportunity for the woman to receive earlier treatment.
"I acknowledge the extraordinary circumstances that faced Waitaha Canterbury following the earthquake in 2011 and the resulting resource constraints, but I do not consider it was reasonable for the woman's neurology referral to have been declined without any further advice being offered."
Dr Caldwell said the service failure was a contributing factor in the woman receiving a neurological review and treatment the woman needed.
Dr Caldwell found the GP who saw the woman in 2015 was in breach of the Code of Health and Disability Services Consumers' Rights.
"The care provided by the GP did not meet the required standard due to the lack of a referral for specialist assessment by a neurologist, and the lack of a follow-up action plan."
Dr Caldwell didn't find the medical centre in breach of the Code, however, she made comments about the nurse's lack of documentation about the conversation over the phone.
She said Waitaha Canterbury has since made multiple changes to its processes, systems and procedures.
She added that she recommended Waitaha Canterbury provide the woman with a formal written apology for the care she received.
The GP has since retired from practice but she recommended he also provide a formal written apology to the woman.
The nurse has been advised by Dr Caldwell to undertake documentation training.
