Deputy Health and Disability Commissioner Dr Vanessa
Caldwell has found Te Whatu Ora – Waitaha Canterbury (WC),
formerly Canterbury District Health Board, and a GP in
breach of the Code of Health and Disability Services
Consumers’ Rights (the Code). In her decision, Dr Caldwell
found that service delivery failures, and failures to
provide a woman with care of a reasonable standard, resulted
in a delayed diagnosis of multiple sclerosis (MS).
A
woman was referred by her GP in 2010 to the ophthalmology
service at the public hospital with sudden and unexplained
vision loss. She was diagnosed with demyelinating optic
neuritis (inflammation of the optic nerve, often associated
with MS). An MRI confirmed the optic neuritis and also noted
several areas of abnormal white matter lesions in the brain,
raising the possibility of primary demyelination. In 2011,
the woman was referred to the neurology service for further
assessment, and was prioritised as ‘semi-urgent,’ but
due to limitations on resources, the referral was declined
and the woman was not seen by the neurology service. The
woman was advised to remain under the care of her
GP.
The woman presented to a GP at a new medical
centre in 2015 due to tingling in her left arm and leg,
which had caused her to fall over on a number of occasions.
The GP ordered screening tests to investigate a provisional
diagnosis of a mini-stroke or an inflammatory disorder, but
did not refer her for specialist assessment by a
neurologist, or put in place a management plan for follow-up
advice or structured review of the test results.
The
woman presented to the medical centre again in 2018 and was
seen by a different GP, whose impression was that she had a
migraine and inner-ear disorder causing vertigo. A few days
later, the woman called the medical centre due to ongoing
symptoms, but the 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.
In 2019, the woman was referred urgently to the
neurology service by the medical centre after presenting to
another GP, who found clinical documentation from 2011
noting that the woman’s MRI had shown features consistent
with demyelination. The woman was diagnosed with MS a couple
of weeks later.
Dr Caldwell acknowledged “the distress
suffered by the woman as a result of the services she
received from Waitaha Canterbury”.
“The possibility of
MS had been raised in 2010, but the diagnosis was confirmed
only nine years later. This delayed diagnosis resulted in
missed opportunities for the woman to obtain earlier
treatment for her condition.
“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.
“I consider the
service failure was a contributing factor to the delay in
the woman receiving the neurological review and treatment
she required,” says Dr Caldwell.
Dr Caldwell also
found a breach of the Code by the GP who saw the woman in
2015.
“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,” says Dr Caldwell.
While Dr
Caldwell did not find the medical centre in breach of the
Code, she made adverse comment about the nurse’s lack of
documentation about telephone discussions and follow-up
actions with the woman.
Following the events of this
case, WC made multiple changes to its processes, systems and
procedures. While WC currently does not have a specific
neurology referral pathway, it follows the Ministry of
Health derived policy or guidelines for triage. WC’s
neurology service has activated an e-triage system, and
immediate management advice and strategies are offered to
the referrer for possible implementation prior to the
neurology clinic appointment. It is now normal process for
departments to respond to both internal and external
referrals and WC has employed a full-time clinical nurse
specialist and a half-time registered nurse specifically for
MS outpatient work.
Taking into consideration the
changes made by WC, Dr Caldwell recommended that WC provide
a formal written apology to the woman for the deficiencies
in care identified, and use the report as a basis for staff
learning. The GP has retired from practice, but Dr Caldwell
recommended he provide a formal written apology to the
woman. She further recommended the nurse undertake training
on documentation.
Editors
notes
The full
report of this case will be available on HDC’s website.
Names have been removed from the report to protect privacy
of the individuals involved in this case.
The
Commissioner will usually name providers and public
hospitals found in breach of the Code, unless it would not
be in the public interest, or would unfairly compromise the
privacy interests of an individual provider or a
consumer.
More information for the media and HDC’s
naming policy can be found on our website here.
HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).
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