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Follow-up of abnormal histology result (14HDC00988)
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14HDC00988, 10 February
District health board ~
Adenocarcinoid tumour ~ Abnormal histology results ~ Systems ~
In 2009, a woman presented to a public hospital with suspected
appendicitis. She underwent an appendectomy performed by a general
surgeon. The appendix was acutely inflamed, and it was removed.
Histology from the appendix showed an adenocarcinoid tumour.
At the time, the district health board (DHB) had no system to
review pathology results electronically, and no backup system. The
histology result was acknowledged by a junior doctor. However it
was not escalated to the general surgeon. No follow-up treatment
was arranged, and neither the woman nor her general practitioner
(GP) were informed of the result.
In 2012, the woman complained to her GP that she had lower
abdominal pain, and her GP referred her to the public hospital.
There, a different general surgeon reviewed the woman. He
considered that her symptoms might be caused by gynaecological
pathology, and referred her to the gynaecological team for review.
The general surgeon did not review the 2009 result.
Approximately three months later, the woman saw the obstetrics
and gynaecology registrar. He noted that the woman was experiencing
painful menstruation, and later performed an MRI, which indicated
that the woman had diffuse abnormality in the pelvis affecting
multiple organs, and that while most of the changes could be
explained by endometriosis, malignancy could not be excluded.
The woman's health continued to deteriorate. She developed
vomiting and diarrhoea, was unable to eat, and was losing weight.
She was reviewed by an obstetrician/gynaecologist (O&G) in the
gynaecology clinic. A report following a CT scan of the woman's
chest, abdomen and pelvis stated: "[S]uspicious for malignancy and
atypical for endometriosis given the extent and bowel involvement."
A gynaecological multidisciplinary meeting (MDM) recommended that
the woman be referred to the gastrointestinal MDM.
The O&G requested a general surgery review of the woman.
During the review, a registrar noted that previous histology of the
woman's appendix had indicated that it was carcinoid (the missed
2009 result). There is no evidence that this was escalated to the
O&G, and the O&G was not made aware of the finding.
The woman was discharged that day. The discharge summary did not
mention the 2009 result, and the woman was not told about it.
Neither did the discharge summary mention the CT report that
recorded the likelihood of malignancy. However, a couple of days
later a referral was made for a colonoscopy, which recorded the
woman's carcinoid histology, and queried recurrence of this. Her
case was discussed at a gastrointestinal MDM, and her 2009 result
was noted at the meeting, as was the CT scan result. It was
recognised that the woman would require surgery, and it was decided
that her case would be taken over by the surgical team. At this
stage, no possible diagnoses other than endometriosis had been
discussed with the woman.
The woman was seen in the general surgical outpatient clinic by
another general surgeon, who reviewed the woman's notes and noted
that in 2009 there had been an incidental finding of an
adenocarcinoid tumour. This was the first time it was identified
that the 2009 result had not been followed up. The general surgeon
said that he did not tell the woman about the 2009 result at that
appointment because more information was needed, as both ovarian
cancer and adenocarcinoid tumour can result in a similar clinical
A staging laparoscopy and peritoneal biopsy were carried out.
The findings were of widespread metastases, but there is no record
that these, or the 2009 result were discussed with the woman at
this time. A few days later, the general surgeon received the
formal pathology from the biopsy and the woman was informed of her
prognosis. This was the first time anyone from the DHB had told the
woman of the tumour identified in 2009.
By now, the woman's condition was such that she was unable to
tolerate surgery. She was referred to palliative care, and sadly,
It was found that the DHB held primary responsibility for the
pattern of errors in this case, which raised concerns about the
systems in place during the period in which the woman received
care. The DHB failed to ensure that appropriate systems were in
place so that abnormal results were escalated appropriately, that
missed results were identified promptly, and that errors were
disclosed in a timely and appropriate manner. The failures resulted
in a pattern of seriously suboptimal care and, accordingly, it was
found that the DHB failed to provide services to the woman with
reasonable care and skill and breached Right 4(1).
Adverse comment was made that the second general surgeon, having
made additional findings that would warrant review of any previous
pathology, did not do so, and that the third general surgeon did
not inform the woman of the missed 2009 result when he became aware
of this. Adverse comment was also made that the DHB was unable to
identify the junior doctor who acknowledged the woman's 2009
A number of recommendations were made, including that the DHB
perform a randomised audit of patient records to assess the
effectiveness of its Electronic Acknowledgement of Results system,
perform an audit evaluating the current access to MRIs (in
particular regarding timeframes), use an anonymised version of
HDC's report as a basis for staff training, and provide a written
apology to the woman's family for the failings identified in the