Medical failure

A failing health paradigm

When I heard this story it resonated with my own struggle with the health system, which, at best has treated me as an 'object', 'health consumer' (how I detest that term!).

I have collected a few terrible stories over recent times. There will be much suffering and cases of abuse that will never make it into the public arena.

One example would be our cleaner D who complained over a long period of allergy symptoms for which her doctor gave stronger and stronger doses of antibiotics (imagine giving antibiotics for an allergy!!). Her doctor didn't seem to notice what we did, which was an increasingly gravely voice and weight loss.

We were rung to be told that D wouldn't be able to come back because she had been diagnosed with cancer – and within a few short weeks she was dead.

In most cases it is not the failure to diagnose, or even the incompetence that is upsetting, but the arrogance and attempts to push things under the carpet. If you listen to the radio item you will hear how badly the family was treated by the hospital who tried to deny that any mistakes had been made.

Hospital fails woman with hernia

Stuff,

20 May, 2013

Staff at Tauranga Hospital missed a diagnosis of hernia and bowel obstruction in a 78-year-old woman for three days, the Health and Disability Commissioner (HDC) said.

The woman was referred to the hospital by her GP who queried the presence of a hernia, and after the patient went into hypoxic cardiac arrest, an operation confirmed a diagnosis of incarcerated femoral hernia.

She died from severe hypoxic brain injury suffered during her cardiac arrest.

The consultant and the registrar who examined the woman, and the Bay of Plenty District Health Board, all breached Code of Health and Disability Services Consumers' Rights, the commissioner said.

The woman was referred to the hospital on a Thursday in mid-2010 with vomiting and dehydration, an irregular pulse, and a groin lump, said the HDC report released today.

She was reviewed by a junior medical registrar and a consultant, provisionally diagnosed with an abdominal malignancy, and a treatment plan was initiated.

The registrar did not mention the possibility of a hernia and the consultant did not read the referral. No differential diagnosis was documented, HDC said.

The day after the patient was admitted, the consultant was rostered in another town, so the woman was reviewed by the registrar alone.

He spoke with the woman's GP, who again queried a diagnosis of hernia and expressed concern that the cause of the vomiting had not been found. The registrar did not inform the consultant of the GP's concerns.

Over the weekend the woman had no medical review for 27 hours, and her condition deteriorated. After a rapid deterioration in clinical signs on the Saturday evening, she vomited, aspirated, and went into hypoxic cardiac arrest. She was resuscitated.

Health and Disability Commissioner Anthony Hill found the consultant breached the Code of Health and Disability Services Consumers' Rights because the consultant did not take reasonable steps to ensure he was adequately informed about the woman's history, and failed to consider a hernia as a differential diagnosis.

The registrar breached the code because he failed to gather the necessary information and adequately inform the consultant, did not seek assistance when the woman's condition did not improve, and his documentation did not meet professional standards.

The Bay of Plenty District Health Board breached the code because it failed in its duty to provide an appropriate standard of care to the woman, and because poor documentation and handover by staff resulted in a failure to ensure the woman received quality and continuity of services.

Champion yachtie gutted by cancer misdiagnosis

NZ Herald,

13 January, 2013

A world champion yachtsman was mistakenly cleared of cancer when pathologists misread his biopsy.

Now Murray Crockett is spending his dying days fighting for compensation to help support his family.

The 66-year-old grandfather was recovering from prostate cancer when he spotted a small red and crusty lump on his shoulder two years ago.

He thought it was a mosquito bite but, given his cancer history, took the precaution of an urgent biopsy.

Auckland surgeon Richard Martin sent the tissue samples to Diagnostic Medlab for assessment.

The results came back as negative a week later, but the surgeon asked for a review of the cells to double-check the cancer had not spread. Again, the findings came back as negative.

Six months later, a lymph node in Crockett's armpit began to swell.

A third review of the biopsy tissue was ordered and the results came back as positive.

By then, Crockett said, it was too late and the cancer had started to spread throughout his body including his bones, lungs and lymph nodes.

He was diagnosed with advanced melanoma and given a few months to live.

"It has broken me, these bastards broke me," he said, looking at the dozen medication bottles cluttering his kitchen bench.

Crockett, whose team won the World ¼ Ton Championship in France in 1975, lives in Warkworth with his partner, Pauline Kent. But the misdiagnosis has forced him to shut down his business, sell his house and quit competitive sailing.

"They have given me a death sentence," he says.

"I can't sit down, I can't mow the lawns. I was surfing at 47 but I'm knackered now. I just can't do it."

A Diagnostic Medlab report written by pathologist Patrick Emanuel said the reading was difficult because the cancer was "extremely small".

The company's histology clinical director Mee Ling Yeong said she did not have enough time to review the file to provide comment but said it was a complex case.

Crockett lodged a treatment injury claim with ACC in September, but it was declined after five independent pathologists reviewed the slides as negative.

However, ACC failed to read specific instructions from the surgeon that impacted on how the slides were reviewed.

The five pathologists were asked to assess the slides again and, this time, three out of the five came back as positive.

The results still did not satisfy ACC, which sought a further, independent review from an oncologist.

Meanwhile, Crockett's life expectancy was shortening by the day. So Crockett's lawyer Simon Buckingham contacted the Herald on Sunday in a desperate bid for help.

The Herald on Sunday made enquiries with ACC, which did a U-turn on its decision and accepted his claim within 12 hours.

Spokeswoman Stephanie Melville confirmed the application for lump sum compensation was fast-tracked and paid before Christmas.

"ACC has great sympathy for Mr Crockett's situation, and we understand his frustration at the time it took to make a decision on his claim," Melville said. "However we believe ACC dealt as promptly as it could with what was a very complex claim which required the opinions of several clinical experts before it could be accepted."

Crockett is hoping that he can be given a new experimental drug. He's awaiting a decision from GlaxoSmithKline.

Department unaware of errors

The Ministry of Health had no idea of repeated, major errors in reading cancer biopsies until a Herald on Sunday investigation.

In May last year, this paper discovered two women had been wrongly diagnosed with cancer. One had her breasts removed unnecessarily and the other's diagnosis and treatment for breast cancer was delayed unnecessarily.

Four other women, or their doctors, came forward to share similar stories, including one who mistakenly had part of her jaw removed because of an incorrect biopsy. In one case, a lab technician had dropped two people's tissue samples on the floor, then mixed them up.

Associate health minister Jo Goodhew ordered an inquiry into the biopsy errors, most of which occurred in pathology laboratories.

Ministry of Health chief medical officer Dr Stewart Jessamine said they only became aware of the "possible systemic issue" in June, after the Herald on Sunday investigation.

He said district health boards were responsible for reporting errors through a Serious and Sentinel Events system, which makes them public annually.

Documents obtained under the Official Information Act show some of the women felt no one was willing to listen until after the Herald on Sunday investigation and the official inquiry.

One woman told the inquiry: "At least someone is taking a little more interest."

One victim waited three months for an apology from the laboratory. Another found out about the error through a psychologist.

Misdiagnosed Bop Cancer Patient Dies

Voxy,

19 January, 2011

Wellington, Jan 19 NZPA - A Bay of Plenty woman who said her doctor repeatedly failed to diagnose her with breast cancer has died.

Caro Galloway died on Monday, leaving behind children Jarred, 11, and Jessica, 16, the Bay of Plenty Times reported.

Ms Galloway sparked an investigation when she complained to the Health and Disability Commissioner about being misdiagnosed.

She said went to a medical centre in 2006 because she was experiencing pain under her right arm, but her doctor told her the pain was caused by hormones.

When she returned after noticing a lump on her breast, Ms Galloway said she was told it was not cancerous, and was repeatedly persuaded against having it removed.

Ms Galloway was only diagnosed in May 2008 after she received a mammogram, ultrasound and biopsy, but by then the cancer had spread to her liver and lungs.

She said in November last year, her life could have been saved if the cancer had been diagnosed on the "first, second, third or fourth" visit to her medical centre.

All she wanted was an apology to her children and husband, Ms Galloway said.

Her uncle Ken Wilson said he did not believe she got an apology.

The Health and Disability Commissioner has yet to rule on the complaint.

Terminal Cancer Misdiagnosis Leads Couple to Throw Life Savings Away on Bucket List

Gawker.com

After Frank was told that his lung cancer had spread to his heart and he had only months to live, he and his wife Wilma sold their house, canceled their health insurance, and put together a bucket list of things they wanted to do before death parted them.

But after spending all their money, plus several thousand dollars more, the Kiwi couple learned the bittersweet truth: Frank was just fine.

"I'm short on my credit cards for 80,000 [New Zealand dollars] and the money we had left went on a business and that didn't work out so we are broke," Wilma said.

In addition to letting their house go at a significant loss, taking expensive trips to Australia and Fiji, and going on lavish spending sprees, Frank also started smoking and drinking coffee — two things he quit after being told he had cancer.

The pair didn't worry about getting into debt because they figured Frank's life insurance would cover it. They returned to Wairoa to pass what they thought were their last days together. "If the pain got too bad I was going to kill myself, but the pain never came ... everyone was surprised I was still alive," Frank told the New Zealand Herald.

In fact, Frank's health was improving: In December 2011, nearly two years after he was diagnosed with terminal cancer, an ultrasound revealed that Frank was cancer-free.

But it would be another two months before a hospice worker finally informed the couple Frank was not going to die. "He said, 'I'm here for the last time'," Frank recalled, "and I said, 'Why'? He said, 'Well you don't have cancer'. We looked at each other and he said, 'Don't you know'?"

Dr. Rob Armstrong of Hawke's Bay Hospital blamed the bad diagnosis on "other medical conditions" that made correctly diagnosing Frank's cancer "difficult and complicated."

Though Dr. Armstrong says Frank is not entirely out of the woods yet, the couple are refusing medical care, saying "they've lost faith in the health system."

An investigation into the misdiagnosis has been launched

Patient demands DHB apology after cancer scare

Stuff,

17 November, 2012

Hamilton man who was told he had cancer and given just weeks to live is seeking a formal apology after finding out he was misdiagnosed.

Eric Scotson - a former US Marine - began setting his affairs in order and spent an emotional time with his family who rushed from the United States after he was told in March that he was terminally ill.

"I was told I had weeks, maybe a few months at best, but as it turns out I'm not doing too badly at all," said the 84-year-old speaking at his home.

The former radiographer was told by a Waikato Hospital surgeon that he needed urgent surgery to remove a tumour from his liver following a routine colonoscopy and CT scan.

"He said I had cancer of the liver and I needed an urgent operation. "I asked if there were any other options and he said ‘palliative care'," said Mr Scotson.

"I chose palliative care, I felt my chances of surviving the surgery were grave and that I needed those few months to get my affairs in order - to say goodbye to my children."

Mr Scotson went home - expecting to die.

Two children arrived from the US at a cost of more than $5000 each, while his wife Angela could not eat, was stressed and upset.

"It was a terrible time for all of us, we were very stressed," she said.

Wanting to get to the bottom of Mr Scotson's diagnosis, his GP ordered more tests.

Follow-up lab tests were done and Mr Scotson was shocked when the results came back showing he did not have cancer.

The Waikato Times first met Mr Scotson just after his cancer diagnosis.

Wanting to share his story about life as a US Marine before he died, a friend of Mr Scotson approached The Times with the idea of running his story as part of our extensive Anzac Day coverage in April.

But Mr Scotson says his relief at having being cleared of cancer has turned to anger that his family had been subjected to a "great deal" of financial and emotional stress.

He has since lodged a formal complaint with the DHB, which communications manager Mary Anne Gill confirmed the DHB had received.

"We investigated the first one and responded. We've sought clarity around the second," she said.

In a letter sent to Mr Scotson's home in October, the surgeon apologised "for any stress that I have caused you".

"Obviously there has been a breakdown in communication and I have arranged an outpatient appointment to go through these issues with you," the surgeon wrote.

But Mr Scotson chose not to keep the "arranged appointment" and said he wanted a formal apology from "higher up the chain".

"But I haven't heard anything of that nature yet, I'm still waiting."