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Names have been removed (except
Waikato DHB and the expert who advised on this case) to protect
privacy. Identifying letters are assigned in alphabetical order and
bear no relationship to the person's actual name.
Waikato District Health Board
A Report by the Health and Disability Commissioner
Table of Contents
Information gathered during
Response to provisional
Opinion: Breach - Waikato District
Appendix A: Independent advice from Dr Patrick
1. On 18 May 2009 Mrs A presented to a
public hospital with abdominal pain. On 19 May 2009 she underwent
an appendectomy performed by locum general surgeon Dr B. Mrs A's
appendix was acutely inflamed, and the perforated appendix was
removed. Histology from the appendix showed that Mrs A had an
adenocarcinoid tumour of the appendix.
2. In 2009 Waikato District Health Board
(WDHB) had no system to review pathology results electronically,
and no backup system. The histology report was acknowledged by a
junior doctor, who initialled the report and underlined the
reference to adenocarcinoid tumour. Dr B did not see the report,
and the junior doctor concerned did not discuss it with her. No
follow-up treatment was arranged, and neither Mrs A nor her general
practitioner (GP) was informed of the result.
3. In Month1 2012 Mrs A complained to
her GP that she had lower abdominal pain, and her GP referred her
to the public hospital and suggested that a colonoscopy was
4. On 27 Month5, general surgeon Dr D
reviewed Mrs A. He considered that her symptoms might be caused by
gynaecological pathology, and referred her to the gynaecological
team for review. Dr D did not review the 2009 histology
5. On 20 Month8, Mrs A saw obstetrics and
gynaecology registrar Dr E. Dr E noted that Mrs A was experiencing
painful menstruation, and later performed an MRI, which indicated
that Mrs A 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.
6. Mrs A continued to deteriorate. She
developed vomiting and diarrhoea, was unable to eat, and was losing
weight. On 5 Month13 she was reviewed by obstetrician/gynaecologist
Dr F in the gynaecology clinic. Dr F requested a CT scan of Mrs A's
"chest abdo pelvis", the report of which stated: "[S]uspicious for
malignancy and atypical for endometriosis given the extent and
bowel involvement." A gynaecological multidisciplinary meeting
(MDM) recommended that Mrs A be referred to the gastrointestinal
7. On 19 Month13, Dr F requested a general
surgery review of Mrs A. During the review, a registrar noted that
previous histology of Mrs A's appendix had indicated that it was
carcinoid (the missed 2009 pathology result). There is no evidence
that this was escalated to Dr F, and Dr F was not made aware of the
8. Mrs A was discharged that day. The
discharge summary did not mention the missed 2009 pathology result,
and Mrs A was not told about it. Neither did the discharge summary
mention the CT report recording the likelihood of malignancy.
However, a couple of days later a referral was made for a
colonoscopy, which recorded Mrs A's carcinoid histology, and
queried recurrence of this.
9. On 24 Month13, Mrs A's 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 Mrs A
would require surgery, and it was decided that her case would be
taken over by the surgical team. On 30 Month13, Dr G (a general
surgeon) performed a colonoscopy, which reported a diagnosis of
10. On 14 Month14, Mrs A was seen in the
general surgical outpatient clinic by general surgeon Dr H. Dr H
reviewed Mrs A'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 appendix pathology had not been
followed up in 2009. Dr H said that he did not tell Mrs A about the
missed 2009 pathology result at that appointment because more
information was needed, as both ovarian cancer and adenocarcinoid
tumour can result in a similar clinical picture.
11. On 15 Month14, a staging laparoscopy and
peritoneal biopsy were carried out. The findings were of widespread
metastases. However, according to Mrs A's family, Mrs A still
thought that she had endometriosis, and was unaware of the missed
result from 2009. On 26 Month14 Dr H received the formal pathology
from the biopsy and on 28 Month14 Mrs A was informed of her
prognosis. Mr A told HDC that this was the first time anyone from
WDHB had told Mrs A of the tumour identified in 2009.
12. It was found that WDHB holds primary
responsibility for the pattern of errors in this case, which raises
concerns about the systems in place during the period in which Mrs
A received care.
13. WDHB had sufficient information to
provide Mrs A with appropriate care. However, a series of failures
meant that it did not do so. Unfortunately, the effect of these was
that Mrs A remained unaware of a potentially lethal tumour until
after it had metastasised, and did not receive the care she
required. The entire system let down Mrs A and her
14. WDHB should have ensured 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. It is very concerning that this did not occur
in this case.
15. The failures by WDHB resulted in a
pattern of seriously suboptimal care and, accordingly, it was found
that WDHB failed to provide services to Mrs A with reasonable care
and skill and breached Right 4(1) of the Code.
16. Adverse comment is made that Dr D,
having made additional findings that would warrant review of any
previous pathology, did not do so, and that Dr H did not inform Mrs
A of the missed 2009 pathology result when he became aware of
17. Adverse comment is also made that WDHB
has been unable to identify the junior doctor who acknowledged Mrs
A's abnormal result in 2009.
18. It is recommended that WDHB perform a
randomised audit of patient records for the past 12 months to
assess the effectiveness of its Electronic Acknowledgement of
Results system. The audit is to ensure that the system complies
with good practice with regard to test reporting, acknowledgment of
results, and follow-up of results. WDHB is to report to HDC on the
outcome of the audit.
19. It is recommended that WDHB use an
anonymised version of this report as a basis for staff training,
focusing in particular on the deficiencies identified in the
report, including regarding open disclosure. WDHB is to provide HDC
with evidence of training having occurred.
20. It is recommended that WDHB consider
conducting regular surgical/pathology meetings, and report back to
HDC on the outcome of the consideration.
21. It is recommended that WDHB perform an
audit evaluating the current access to MRIs, in particular
regarding timeframes. WDHB is to report to HDC on the outcome of
22. It is recommended that WDHB provide a
written apology to Mrs A's family for the failings identified in
this report. The apology is to be sent to HDC for forwarding.
23. The Commissioner received a complaint
from Mr A about the services provided by the public hospital to his
wife, Mrs A (dec), from May 2009. The following issue was
identified for investigation:
• Whether Waikato District Health Board
provided Mrs A with an appropriate standard of care between May
2009 and her death in 2013.
24. An investigation was commenced on 15
25. The parties directly involved in the
Mr A Complainant
Waikato District Health Board Provider
Also mentioned in this report:
Dr B Locum general surgeon
Dr D General surgeon
Dr E Obstetrics and gynaecology
Dr F Obstetrician/gynaecologist
Dr G General surgeon
Dr H General surgeon
Dr I Colorectal and laparoscopic surgeon
26. Information was also reviewed from:
27. Independent expert advice was obtained
from general surgeon Dr Patrick Alley (Appendix A).
Information gathered during
Appendectomy and receipt of pathology result
28. On 18 May 2009, Mrs A (who was 46 years
old at the time) was referred by her general practitioner (GP), Dr
C, to the Emergency Department (ED) with suspected appendicitis.
She was admitted under the care of locum general surgeon Dr
B, and diagnosed with acute appendicitis.
29. On 19 May 2009, Dr B performed an
appendectomy on Mrs A. A general surgical registrar dictated
the operation report, documenting: "Acute suppurative
perforated appendicitis with an inflammatory mass." Dr B
requested histology from the appendix. On 22 May 2009, Mrs A was
discharged. Dr B told HDC that she "did not make any arrangements
to follow [Mrs A] up in out-patients as there was no indication for
this on clinical grounds".
30. On 28 May 2009, a pathologist produced
the histology report. This documented:
"APPENDIX, APPENDICECTOMY: ACUTE SUPPURATIVE APPENDICITIS WITH
ADENOCARCINOMA/ADENOCARCINOID TUMOUR, IMMUNOSTAINS
31. On 3 June 2009, the histology report was
updated, stating that the immunostain panel showed appearances
consistent with an adenocarcinoid tumour.
32. No follow-up treatment was arranged, and
Mrs A and her GP were not informed of the result. WDHB's Serious
Incident Review Report (the review) records that at that time
there was no system to review pathology results electronically. It
further records that the histology report, indicating a tumour, was
acknowledged by a junior doctor. The histology report was
initialled, and the reference to adenocarcinoid tumour was
underlined, but the initials were not dated. WDHB's review records
that WDHB cannot confirm the name of the doctor, as the medical
rosters from the time do not have allocated to the area any staff
with the same initials as those that appear on the pathology
report. WDHB noted: "It is possible that the initials match a
doctor who was from the relieving pool."
33. The review records that the discharge in
2009 was coded as adenocarcinoma of the appendix. However, the
clinical coding was not reviewed by consultants and signed off
"unless they participate[d] in clinical coding audits which are not
mandatory". WDHB said that there is no evidence that the result was
escalated to Dr B, and in 2009 there was no back-up system in
34. Dr B told HDC that she did not see the
histology report, and there was no conversation with her about it.
She said that her expectation was that all pathology results would
be seen by her for acknowledgment. Dr B stated:
"There was no mechanism in place for me to identify those
results that I had not personally seen … All of the junior doctors
working under my supervision had been informed of [my expectation
that all pathology results would be seen by me for acknowledgment],
and were aware of the need to escalate any abnormal results to
35. Dr B said that all relieving doctors had
been through departmental based orientation, which included the
expectations about escalating results.
36. WDHB said that Dr B's usual practice was
to follow up every patient who had complicated surgery or an
abnormal result. It said that until receipt of the pathology
result, there was no other indication that follow-up was required
in Mrs A's case.
37. Dr B stated:
"If I had seen the pathology report, I would have arranged
follow up in the surgical clinic for [Mrs A]. This would have been
to inform her of this finding, and to arrange further
investigations. I would also have referred her to the next
Gastrointestinal Multidisciplinary Team Meeting for discussion of
38. Dr B said that subsequently she was not
informed of the result of the biopsy, and she did not receive any
update on Mrs A's condition until she became aware of Mr A's
complaint to HDC.
39. In 2009 WDHB had in place a policy
called "Delegated Responsibilities of Resident Medical Officers
(RMOs) - When to call the Consultant", which stated that the RMO
must contact the consultant in the following
"Any patient for whom the diagnosis or management is unclear,
and for whom delay of management until the next ward round would be
If a patient appears to have had a complication following a
procedure with which the RMO is not familiar."
40. The policy does not specifically refer
to the responsibilities of RMOs when reviewing pathology
Decline in Mrs A's health during 2012
41. On 26 Month1, Mrs A had an appointment
with Dr C, during which she complained of lower abdominal pain. Dr
C made a surgical referral, suggesting that a colonoscopy was
indicated. On 8 Month2, the public hospital wrote to Mrs A to
advise her that it had received the referral, and that she had been
added to the General Surgical Outpatient wait list with a waiting
time of two to six months. Subsequently Mrs A developed nausea and
a decrease in appetite, and her pain became much worse during
menstruation and when she had bowel motions. Mrs A was given an
appointment to be seen on 27 Month5.
42. On 27 Month5, general surgeon Dr D saw
Mrs A. He did not review the missed 2009 pathology result. He told
HDC that Mrs A's past medical history did include an appendectomy
three and a half years earlier, but that this was not mentioned in
the referral letter. He noted that the lifetime risk of a woman
having undergone an appendectomy is approximately 20% and, as it is
so common, it does not influence the normal treatment of patients.
He noted that only 0.2% of appendectomy specimens reveal unexpected
malignancy requiring further surgery. He stated:
"Therefore it is not normal clinical practice in the outpatient
setting to check old histology reports as finding a cancer missed
from an earlier error is such an extraordinarily rare event."
43. Dr D felt that Mrs A's symptoms might be
caused by gynaecological pathology, and decided that there was no
need to perform a colonoscopy at that stage. Dr D referred Mrs A to
the gynaecological team for review and treatment, and informed Dr C
of this by letter. Dr D also told Dr C: "Abdominal examination
today revealed some lower abdominal tenderness and I wondered if
there was in fact a pelvic mass present. Rectal examination
revealed at least an enlarged uterus but this might also be the
lower aspect of a mass." Dr D ordered an urgent pelvic ultrasound
scan to look at Mrs A's uterus and ovaries.
44. WDHB said that Mrs A's reported symptoms
were "more indicative of [a] gynaecological rather than
gastrointestinal origin", and so the appendix pathology was not
reviewed by the gastrointestinal team.
45. On 7 Month7, Mrs A had the pelvic
ultrasound. The radiology report states:
"[The] left ovary appears enlarged and part of a solid complex
cystic and solid area … Possibilities … include a tubo ovarian
abscess and hydrosalpinx. Other possibilities however
would include a mixed cystic and solid tumour."
46. It was recommended that Mrs A undergo a
repeat scan in six weeks' time.
47. On 15 Month7, Dr D wrote to Dr C and
advised that the scan had shown "a complex pelvic abnormality". Dr
D referred Mrs A to the gynaecological clinic and stated in his
letter to Dr C that there was no need for her to be followed up in
the surgical clinic.
48. On 11 Month8, Mrs A was given an
appointment with the gynaecology service for 20 Month8. On 20
Month8, obstetrics and gynaecology registrar Dr E saw Mrs A, made a
plan for "tumour markers" and "an MRI to further evaluate the
mass", and noted that Mrs A's last two or three menstrual periods
had been painful, which was new, as prior to this she had not had
painful periods. Examination revealed "right adnexal
tenderness", but no other abnormalities were noted.
49. In the interim, Dr E advised Dr C to
refer Mrs A back to the gynaecological clinic should her symptoms
50. On 26 Month9, Mrs A had an appointment
with Dr C and told him that the pain was worse. Dr C noted: "[C]an
get severe about twice daily." On 28 Month9, Dr C re-referred Mrs A
to the gynaecological clinic, stating that Mrs A's symptoms were
worse and asking whether they could bring forward the MRI. Dr C
documented in the referral letter: "High Suspicion of Cancer … I do
worry this woman may turn out to have ovarian cancer."
51. On 4 Month12 an MRI of Mrs A's pelvis
was performed. The report documented:
"[D]iffuse abnormality in the pelvis affecting multiple organs
The appearances are most in keeping with severe extensive
infiltrative endometriosis …
Although most of the changes can be explained by endometriosis,
a superadded malignancy cannot be excluded …"
52. The report suggested that a CT scan of
Mrs A's abdomen and pelvis be performed. WDHB stated that, as the
gynaecological team thought that the symptoms indicated
gynaecological pathology, the team did not review the missed 2009
53. Mrs A's symptoms continued to get worse.
She had vomiting and diarrhoea, was unable to eat, and lost weight.
On 5 Month13 Mrs A was reviewed by obstetrician/gynaecologist Dr F
in the gynaecology clinic. He told HDC that because endometriosis
or a malignancy was suspected, he arranged for Mrs A to be admitted
to the Gynaecology Ward on 8 Month13. Dr F requested that a CT scan
of Mrs A's "chest abdo pelvis" be carried out, and a blood test and
a nutritional assessment be performed.
54. On 12 Month13 the CT scan was performed.
The report by a radiology registrar stated that there was marked
hydronephrosis of the left kidney and ureter, a moderate to
large volume of free fluid within the abdomen and pelvis, a mass in
the left side of the pelvis, and ill-defined soft tissue between
the uterus and right pelvic bowel loops. The report noted: "No
convincing evidence of distant disease is seen to suggest
55. On 12 Month13 Mrs A was discharged. Her
discharge summary stated that the CT was carried out "to check for
distant organ involvement/calcification and to look for any ?
malignancy", and that it gave the impression of an "Ovarian
56. On 16 Month13, the CT report from 12
Month13 was reviewed by a radiologist, and amended to state:
"[S]uspicious for malignancy and atypical for endometriosis given
the extent and bowel involvement. Peritoneal fluid cytology and
peritoneal biopsy are recommended." Also on this date Mrs A's case
was discussed at a Gynaecology Multidisciplinary meeting (MDM) at
the public hospital. Notes from this meeting record that it was
recommended that Mrs A be referred to the Gastrointestinal MDM and
ascitic fluid be obtained for cytology. The MRI from 4
Month12 and the CT report (from 12 Month13), including the amended
report, were referred to.
57. On 18 Month13, an ascitic tap, to drain
the fluid, was carried out under ultrasound guidance. The fluid was
sent for cytology. The cytology report identified:
"Occasional cells appear atypical however these are in keeping with
degenerative changes … CELL BLOCK PENDING." On receipt of the final
cell results, the cytology report was updated to record "reactive
mesothelial cells" only.
58. On 19 Month13, Dr F requested a general
surgery review of Mrs A. The review was conducted by a colorectal
registrar, who discovered the missed 2009 pathology result
indicating adenocarcinoma. The registrar recorded in the clinical
records at 3pm: "Noted previous appendectomy histology -
carcinoid." However, there is no record that the registrar
discussed this with Mrs A.
59. WDHB said that the carcinoid histology
entry "was made by a general surgery registrar who was asked to
provide a pre-discharge consultation". The entry does not specify
whether the finding was escalated or discussed with anyone. WDHB
said that there is no evidence that the finding was escalated to Dr
F. Dr F said that he was not made aware of the finding.
60. WDHB said that its "[d]iscussion with
[Dr F] indicates that this was a handover of care to general
surgery and follow up on this documentation would not be expected
by the gynaecological team".
61. Mrs A was discharged at 3.52pm that day.
The discharge summary prepared by a house officer documents that
the plan was that Mrs A would be booked in for a colonoscopy, and
that her case would be discussed at the next MDM. It is also noted:
"Both specialties will be keeping in touch with one another for a
multidisciplinary approach." The discharge summary states: "No
convincing evidence of distant disease is seen to suggest
malignancy." The summary does not mention the carcinoid appendix
diagnosis, and Mrs A was not told about the 2009 pathology result.
The discharge summary also does not mention the updated CT report
of 16 Month13 stating that the scan was suspicious for malignancy.
WDHB said that this information was omitted from the discharge
62. On 22 Month13, a referral was made for Mrs A to have a
colonoscopy. The referring clinicians were documented as being Dr F
and the colorectal registrar. The referral records Mrs A's previous
history of an appendectomy and the carcinoid histology, and queries
63. On 24 Month13 Mrs A's case was discussed at a
Gastrointestinal MDM. At the meeting, Mrs A's previous histology
from 2009 recording the adenocarcinoid tumour was noted, as was the
recent scan result suggesting the likelihood of malignancy. It was
recognised at the meeting that Mrs A would require surgery, and so
it was decided that her case would be taken over by the surgical
team. At that stage no possible diagnoses other than
endometriosis had been discussed with Mrs A.
64. On 30 Month13, Mrs A had a colonoscopy performed by Dr G. It
is recorded on the colonoscopy report that Mrs A had an
appendectomy in 2009, and that the colonoscopy was indicated for a
"[p]revious small appendiceal carcinoid. Now has left ovarian
mass." The report documented that the diagnosis was "Rectal
Polyp(s) ". It stated that histology had been ordered, and that the
GP was to check the histology.
65. WDHB said that at that time the previous appendiceal
carcinoid finding was not identified as being a missed diagnostic
error, because it was not known by the clinicians that the
pathology result had not been followed up in 2009. As a result, the
2013 findings were referred for investigation as a possible
"recurrence" from 2009. WDHB said that this was also why the error
was not communicated to Mrs A until further investigations had been
66. On 14 Month14, Mrs A was seen in the general surgical
(colorectal) outpatient clinic. General surgeon Dr H told HDC that
when he saw Mrs A in the clinic, he reviewed her notes and noted
that "back in 2009 when she had the appendectomy there was an
incidental finding of an adenocarcinoid tumour with a histology
report stating that the tumour was 7mm in diameter". Dr H also
reviewed and noted the recent CT and MRI scan reports. He advised
that he felt that it was necessary to admit her acutely on the day
for further investigation, and to optimise her nutrition. He stated
"This was due to the fact that the appearance on the scans could
be secondary to a primary ovarian cancer with peritoneal
metastasis, or an appendiceal adenocarcinoid with metastasis. I
felt that it would be necessary to obtain tissue sample and to
stage the disease via a laparoscopy."
67. That day, Dr H wrote to Dr C noting: "[P]revious
perforated appendix with an adenocarcinoid tumour in there. This
was not formally followed up." WDHB said that this was the first
time that the appendix pathology was identified as not having been
followed up in 2009.
68. Dr H told HDC that he did not tell Mrs A about the missed
2009 pathology result at the clinic appointment because more
information was needed first, "as both ovarian cancer and
adenocarcinoid tumour can result in [a] similar clinical
69. On 15 Month14, a staging laparoscopy and peritoneal biopsy
were carried out. The operation report dictated by Dr H notes that
the findings were "[w]idespread peritoneal mets" (metastases). On
16 Month14 Mrs A was discharged by colorectal and laparoscopic
surgeon Dr I. The discharge summary notes that the findings were:
"Gross ascites, widespread peritoneal carcinomatosis -
involving all areas + small bowel serosa, mesentery. " It
also noted: "We will see you in clinic in about 3 weeks time to
discuss the results of the biopsy and further plans."
70. Although Mrs A's discharge summary documented the carcinoma,
there is no record that this was discussed with Mrs A and,
according to her family, she still thought she had endometriosis
and remained unaware of the finding from May 2009.
71. On 26 Month14 the formal pathology for the peritoneal biopsy
was reported. The report confirmed metastases. It
"FEATURES IN KEEPING WITH AN ADENOCARCINOID TUMOUR. IT IS NOTED
THAT THIS PATIENT HAS HAD A PREVIOUSLY DIAGNOSED ADENOCARCINOID
TUMOUR OF THE APPENDIX."
72. On 28 Month14, Dr H documented in Mrs A's clinical notes:
"Understandably devastated with prognosis today, daughter &
husband also angry at perceived delay in
73. At this appointment, Mrs A and her family were told about
the history of the appendicitis and the subsequent tumour found at
histology. This was the first time Mrs A learnt of the tumour found
74. On 4 Month15, Dr I told Mrs A and her family that she could
not have surgery as "she would not tolerate the surgery". Mrs A was
referred to oncology for consideration of palliative
75. Mrs A was referred to palliative care, and sadly, died.
Open disclosure policy
76. During the time of these events, WDHB's Open Disclosure
Policy stated the following:
"1.2 When a patient is harmed while receiving clinical
treatment, it is important that the health practitioner team
respond in a manner that meets the patient's needs and fulfils the
professional ethical and legal responsibilities of health
practitioners. It is expected that the senior clinician responsible
for the care of the patient discloses the situation that has
arisen, in an open honest and accountable manner.
1.3 Expectation of Open Disclosure
… Disclosure may occur in stages that allow the provider to
address the issues in a way that allows the patient and their
family to understand and process the information without being
overwhelmed. This should not be a reason to withhold
Patients and their families are usually concerned about what and
how the harm occurred, why it happened, and what the long term
consequences for care are. …
2.1 Initial contact
Contact should be made in a timely manner. It is expected that
there will be contact with the patient and their family as soon as
possible after the event i.e. at least within 24 hours of the event
Systems in place during 2009
77. WDHB told HDC:
"Systems in place in 2009 were woefully inadequate at
facilitating review of patient results … with multiple results
being generated under [consultants'] name[s] in multiple settings …
[F]ollowing these results as an individual consultant is next to
impossible where there is no supporting system. … We rely on
delegated authority but this failed in this case … [Dr B's]
non-awareness of the result was a systems issue."
78. WDHB acknowledged that documentation in a patient's clinical
record is not sufficient communication between teams to instigate
the escalation of abnormal/unexpected findings, and said that
documentation must be backed up by verbal communication.
79. WDHB stated: "It was well known that there were system
failures." It said that in 2010, Procedure 3703 Electronic
Acknowledgement (laboratory and radiology results) was released. As
part of this, data reports were meant to be run in the first week
of every month and distributed to the chief medical advisor, group
managers, and clinical directors for action and follow-up with
their staff. WDHB said that it has not found evidence of these
reports having been run, although it also noted: "It is unlikely
these reports would have assisted any consultant to identify that
follow up for the [pathology] result had not occurred as this would
have required a case review."
80. WDHB also said that the system introduced in 2010 for
electronic acknowledgement of results did not include what
follow-up was arranged, so that, even though the 2009 result was
eventually acknowledged in Month13, that did not indicate whether
or not there had been any follow-up in 2009.
81. On 26 November 2015, WDHB made an amendment to its 2013
Electronic Result Acknowledgement Guideline (1452) to ensure that
only consultants can acknowledge histology results. WDHB said that
all consultants/Senior Medical Officers (SMOs) have been advised
that they are responsible for reviewing results, and that this
cannot be delegated to an RMO, and that this information is also
included in the orientation information for new SMOs. To evaluate
this, WDHB advised that a six-month post-implementation audit to
review the outcome of 10 randomly selected results would be carried
82. One of the main principles of this policy is that electronic
acknowledgement implies that any action required had been taken or
is being organised. The expectation is that all results are
acknowledged within 3 working days of being finalised. Any results
not acknowledged within 10 days of being finalised will be
considered non-compliant with acceptable clinical practice and will
be investigated by the team management.
83. A further addition to the guideline is that in the event of
an unexpected abnormal test result, pathology will "endeavour to
liaise with the lead clinical consultant … but the ultimate
responsibility will lie with the consultant whose team ordered the
84. In response to the provisional opinion, WDHB stated that the
proportion of acknowledged laboratory results increased from 90% to
99.9% and for radiology results from 61% to 97%. It also stated
that there has been an improved orientation to Electronic
Review of previous appendectomy pathology in 2012
85. In respect of Dr D not reviewing Mrs A's previous pathology
result in 2012, WDHB told HDC:
"Outpatient clinics in General Surgery are restrictive of time;
we usually have no more than 10 minutes to assess each patient.
Abdominal pain is perhaps the most common symptom we see, and a
relatively large proportion of patients (perhaps 20%) have had
appendicectomy in previous years. It is not routine practice to
check the pathology of the appendices removed years prior. … In the
event it was routine practice it would place significant time
pressures on surgeons in already time restricted outpatient clinics
for very little or no gain. …
Even when subsequent tests showed an ovarian mass, this would
not, in my (or my colleagues) practice necessarily mandate a review
of old appendix pathology. The only exception would be if there was
something particularly strange or unusual about the pelvic mass
that just 'did not fit'. This was not the case here."
86. Mr A, Waikato District Health Board and the individual
clinicians involved were asked to comment on the relevant sections
of my provisional opinion.
87. Waikato District Health Board accepted the recommendations
as stated in the provisional opinion. The individual clinicians had
nothing further to add.
88. Mr A responded and his comments have been incorporated into
the report where relevant.
Opinion: Breach -
Waikato District Health Board
89. Mrs A was seen by multiple WDHB clinicians from May 2009,
particularly between Month1 and Month15.
90. In my view, some aspects of the care received by Mrs A
between May 2009 and Month15 were seriously suboptimal. WDHB and
the staff involved in Mrs A's care had a responsibility to take all
reasonable steps to ensure that services were provided to her with
reasonable care and skill. As stated previously, district
health boards are responsible for the operation of clinical
services within hospitals, and can be held responsible for any
service failures. WDHB had an organisational duty to ensure that
care was provided with adequate care and skill.
91. In this case, the individual health professionals who
provided care to Mrs A bear some responsibility for the failures
but, taking into account the pattern of errors and the number of
doctors involved in Mrs A's suboptimal treatment, I am of the view
that in this case the failures arose as a result of systems issues.
I therefore consider that WDHB holds primary responsibility for the
very poor standard of care provided.
92. On 18 May 2009 Mrs A presented to the public hospital with
abdominal pain. On 19 May 2009 she underwent an appendectomy
performed by Dr B. Her appendix was acutely inflamed and the
perforated appendix was removed. Mrs A was discharged on 22 May
2009 with no planned follow-up.
93. Histology from the appendix was requested which, in addition
to an inflamed appendix, indicated the presence of an
adenocarcinoid tumour. Following receipt of immunostains on 3 June
2009, it was confirmed that Mrs A had an adenocarcinoid tumour of
94. In 2009 WDHB had no system to review pathology results
electronically, and no backup system. While WDHB had a policy for
when junior doctors should escalate matters to a consultant, this
did not cover who had accountability regarding the acknowledgment
of results, and who was able to acknowledge results, and did not
make clear the circumstances in which abnormal results were to be
95. In Mrs A's case, the report was acknowledged by a junior
doctor who initialled the report and underlined the reference to
adenocarcinoid tumour. The initials are not dated. WDHB has been
unable to confirm the doctor's name, as the initials do not match
any staff allocated to the area, but suggested that "it is possible
that the initials match a doctor who was from the relieving
96. Dr B told HDC that she did not see the report, and said that
the junior doctor concerned did not discuss it with her. Dr B said
that her expectation was that all pathology results would be seen
by her for acknowledgement, and that all junior doctors working
under her supervision were informed of that expectation. Dr B
stated that all relieving doctors had been through departmental
based orientation, which included the expectation about escalating
results. She said that there was no mechanism in place for her to
identify that there were results she had not seen personally.
97. Unfortunately, no follow-up treatment was arranged, and
neither Mrs A nor her GP, Dr C, was informed of the
98. My expert advisor, general surgeon Dr Patrick Alley, advised
me that the system in existence at WDHB at that time had major
defects, in that:
• It assumed clinical knowledge by relatively junior
practitioners about the significance of results.
• There was no compulsion on junior staff to alert their seniors
to abnormal results.
• WDHB was unable to identify who signed off the result.
99. Dr Alley advised: "This failure by an unidentified RMO to
escalate the result of the histology on the appendix is the primary
root cause of this serious adverse event."
100. I am highly critical of WDHB's approach to dealing with
abnormal results at the time, which in this case did not ensure
appropriate escalation of Mrs A's abnormal result. The system
relied on junior doctors to escalate results, but lacked any clear
policy outlining if or when results ought to be escalated, and
provided no alternative mechanism through which consultants were
able to identify results they had not seen personally. I note that
the junior doctor underlined the reference to an adenocarcinoid
tumour, and can be taken to have understood its
101. DHBs rely on the ability of junior doctors to carry out
certain tasks independently, and specialists should be able to
expect a certain level of competence from junior staff. I accept
that it is impracticable for a specialist to oversee every decision
made by junior doctors, and tasks may be delegated where
appropriate. As WDHB had no system to identify the junior doctor
concerned, it is not possible for me to assess whether it was
reasonable in the circumstances for that doctor to review Mrs A's
pathology result. I am concerned that WDHB has been unable to
identify the doctor.
102. While I am conscious that the ultimate responsibility for
Mrs A's care rested with Dr B, I acknowledge that, in this regard,
Dr B was dependent on an inadequate system, and note that WDHB told
HDC that due to the system issues, it was "next to impossible" for
individual consultants to follow up results.
103. I therefore consider that, in the circumstances, the
primary cause of the error was a systems failure within
104. In Month1 Mrs A complained to her GP, Dr C, that she had
lower abdominal pain. Dr C referred Mrs A to the public hospital,
suggesting that a colonoscopy was indicated. An appointment was
made to see Mrs A on 27 Month5 at the general surgical unit.
105. On 27 Month5 Dr D reviewed Mrs A and considered that her
symptoms might be caused by gynaecological pathology, and decided
that there was no need to perform a colonoscopy. Dr D referred Mrs
A to the gynaecological team for review and ordered a pelvic
ultrasound scan to look at Mrs A's uterus and ovaries.
106. Dr Alley advised me that it was not unreasonable to
consider that Mrs A's symptoms were of gynaecological origin. In
light of the history elicited by Dr D, Dr Alley advised that he
would not regard the failure to carry out a colonoscopy as a
departure from normal practice.
107. Dr D did not review the missed 2009 pathology result. He
told HDC that Mrs A's past medical history included an appendectomy
three and a half years earlier, but that this was not mentioned in
the referral letter. He noted that the lifetime risk of a woman
having undergone an appendectomy is approximately 20% and, as it is
so common, it does not influence the normal treatment of patients.
He noted that only 0.2% of appendectomy specimens reveal unexpected
malignancy requiring further surgery. He stated that it is not
normal clinical practice in the outpatient setting to check old
histology reports, as finding a cancer missed from an earlier error
is an extraordinarily rare event. I acknowledge WDHB's comments
regarding routine practice and the time restrictions on outpatient
clinics, including that usually there is no more than 10 minutes to
assess each patient.
108. However, Dr Alley advised that he was moderately critical
that Dr D did not review the missed 2009 pathology result. Dr Alley
stated that although originally Mrs A had presented with abdominal
pain, on examination Dr D had made additional findings (namely
suspicion of an abdominal mass and a likely pelvic mass) that Dr
Alley considered "would be a stimulus to review any previous
pathology". I also note Dr Alley's concern with the indication that
outpatients "slots" in General Surgery at WDHB are generally no
more than 10 minutes.
109. As to time, I do not accept that senior clinicians are
incapable of determining their ability to assess a patient
appropriately in the time available to them. Suspicion of an
abdominal mass and a likely pelvic mass should have been sufficient
information to place Dr D on enquiry.
110. Taking into consideration the information available to me,
while I acknowledge that a previously missed pathology result is a
rare event, I am critical that Dr D, having made additional
findings that would warrant review of any previous pathology, did
not do so.
111. On 20 Month8 Mrs A saw obstetrics and gynaecology registrar
Dr E. Dr E planned to perform an MRI to evaluate the mass, and
noted that Mrs A was by then experiencing painful
112. By 26 Month9, Mrs A's pain had worsened, and Dr C referred
Mrs A back to the gynaecology clinic, stating that Mrs A's symptoms
were worse and asking whether the MRI could be brought forward. Dr
C documented in his referral letter: "High Suspicion of Cancer … I
do worry this woman may turn out to have ovarian cancer." An MRI of
Mrs A's pelvis was performed on 4 Month12.
113. WDHB said that the gynaecology team did not review the
missed 2009 pathology result as they thought that the symptoms
indicated a gynaecological pathology. Dr Alley noted that, being
unaware of Mrs A's past history, the gynaecologists managed Mrs A
as though she was a de novo presentation. Dr Alley advised that if
that had been correct, Mrs A would have been seen within a
114. I also note Dr Alley's view that "[t]he delay in getting
the MRI done is significant and is independent of what [Mrs A's]
history was". I agree.
115. The MRI report documented that Mrs A had "diffuse
abnormality in the pelvis affecting multiple organs". It stated:
"Although most of the changes can be explained by endometriosis, a
superadded malignancy cannot be excluded." The report suggested
that a CT scan of Mrs A's abdomen and pelvis be
116. Mrs A continued to deteriorate. She developed vomiting and
diarrhoea, was unable to eat, and was losing weight. On 5 Month13
she was reviewed by obstetrician/gynaecologist Dr F in the
gynaecology clinic, and on 8 Month13 she was admitted to the
gynaecology ward. Dr F requested a CT scan of Mrs A's "chest abdo
117. Initially the CT scan report did not identify a potential
malignancy. However, the report was reviewed by the radiologist
four days later and amended to state: "[S]uspicious for malignancy
and atypical for endometriosis given the extent and bowel
involvement. Peritoneal fluid cytology and peritoneal biopsy are
118. The gynaecology MDM recommended that Mrs A be referred to
the gastrointestinal MDM and that ascitic fluid be obtained for
cytology, which was done later and did not identify malignant
119. On 19 Month13, Dr F requested a general surgery review of
Mrs A. The registrar who carried out the review noted the 2009
histology report of Mrs A's appendix, which indicated
adenocarcinoma. There is no evidence that this was escalated to Dr
F, and Dr F said that he was not made aware of the finding.
120. Mrs A was discharged that day, and the discharge summary
prepared by a house officer records that she was to be booked in
for a colonoscopy, and that her case would be discussed at the next
gastrointestinal MDM. The discharge summary does not mention the
missed 2009 pathology result, and Mrs A was not told about it. The
discharge summary also does not mention the CT report, which
recorded a likelihood of malignancy. However, a couple of days
later a referral was made, which noted the previous carcinoid
result and queried a recurrence.
121. On 24 Month13, Mrs A's case was discussed at a
gastrointestinal MDM, and her 2009 result was noted at the meeting,
as was the CT scan result suggesting the likelihood of malignancy.
It was recognised that Mrs A would require surgery, and it was
decided that her case would be taken over by the surgical team. On
30 Month13 Dr G performed a colonoscopy, which reported a diagnosis
of rectal polyps.
122. WDHB stated that the missed 2009 pathology result was not
identified as a missed diagnosis at that time because the
clinicians were unaware that the missed 2009 pathology result had
not been followed up in 2009. As a result, the recent scan result
was referred for investigation as a possible "recurrence" of the
123. Dr Alley advised that it is not possible to cite a
recurrence of a problem that has not been treated and is not in the
consciousness of the clinicians caring for the patient. Dr Alley
advised that the missed diagnosis should have been identified and
communicated to Mrs A. I agree.
124. On 14 Month14 Mrs A was seen in the general surgical
outpatient clinic by Dr H. Dr H reviewed her notes and noted that
in 2009 there had been an incidental finding of an adenocarcinoid
tumour. WDHB stated that this was the first time it was identified
that the appendix pathology had not been followed up in 2009. Dr H
said that he did not tell Mrs A about the missed appendix pathology
at that appointment because more information was needed, "as both
ovarian cancer and adenocarcinoid tumour can result in a similar
125. On 15 Month14 a staging laparoscopy and peritoneal biopsy
were carried out. The findings were of widespread metastases.
However, according to Mrs A's family, Mrs A still thought she had
endometriosis, and was still not aware of the missed diagnosis from
2009. On 26 Month14, Dr H received the formal pathology from the
biopsy, and on 28 Month14 he informed Mrs A of her prognosis. Mr A
told HDC that this was the first time anyone from WDHB had told Mrs
A of the tumour identified in 2009.
126. Early in his clinical management of Mrs A, Dr H was aware
that a significant missed diagnosis had occurred. Dr Alley stated:
"[H]e was, in my view appropriately cautious in waiting for a firm
histological diagnosis to be sustained. While metastatic disease
from the missed adenoid carcinoma was very likely, it could not be
absolutely confirmed until the histology was available." I agree
that the metastatic nature of the carcinoma could not be confirmed
with Mrs A at this stage. However, I consider that Dr H should have
had a frank conversation with Mrs A about the fact that there had
been a missed 2009 pathology result, and the possible implications
of this. I am critical that this did not occur.
127. Dr Alley advised me that WDHB should have conceded its
error earlier than it did. He noted that there is some
mitigation, as the pathology was uncertain, but he considers that
there was delayed open disclosure. I agree, and I am concerned that
while WDHB's Open Disclosure Policy places an emphasis on
clinicians contacting the patient and his or her family as soon as
possible when an adverse event has occurred, Mrs A was not informed
of the missed result when this was discovered.
128. This is a complex case covering several years and involving
many clinicians. In my opinion, in this case WDHB holds primary
responsibility for the pattern of errors, which raises concerns
about the systems in place during the period in which Mrs A
129. WDHB had sufficient information to provide Mrs A with
appropriate care. However, a series of failures meant that it did
not do so. Unfortunately, the effect of this was that Mrs A
remained unaware of a potentially lethal tumour until after it had
metastasised, and did not receive the care she required. The
entire system let down Mrs A and her family.
130. I consider that WDHB should have ensured that appropriate
systems were in place so that abnormal results were escalated
appropriately, missed results were identified promptly, and errors
were disclosed in a timely and appropriate manner. It is very
concerning that this did not occur in this case.
131. In my view, the failures by WDHB resulted in a pattern of
seriously suboptimal care and, accordingly, I find that WDHB failed
to provide services to Mrs A with reasonable care and skill and
breached Right 4(1) of the Code of Health and Disability Services
Consumers' Rights (the Code).
132. In addition, I am critical that Dr D, having made
additional findings that would warrant review of any previous
pathology, did not do so. I am also critical that Dr H did not
inform Mrs A of the missed 2009 pathology result when he became
aware of this.
133. I am also concerned that WDHB has been unable to identify
the junior doctor who acknowledged Mrs A's abnormal result in
134. I recommend that WDHB perform a randomised audit of patient
records for the past 12 months to assess the effectiveness of its
Electronic Acknowledgement of Results system. The audit is to
ensure that the system complies with good practice with regard to
test reporting, acknowledgment of results, and follow-up of
results. WDHB is to report to HDC on the outcome of the audit
within six months of the date of this report.
135. I recommend that WDHB use an anonymised version of this
report as a basis for staff training, focusing in particular on the
deficiencies identified in the report, including regarding open
disclosure. WDHB is to provide evidence of training having occurred
within six months of the date of this report.
136. I recommend that WDHB consider conducting regular
surgical/pathology meetings, and report back to HDC on the outcome
of the consideration within three months of the date of this
137. I recommend that WDHB perform an audit evaluating the
current access to MRIs, in particular regarding timeframes. WDHB is
to report to HDC on the outcome of the audit within six months of
the date of this report.
138. I recommend that WDHB provide a written apology to Mrs A's
family for the failings identified in this report. The apology is
to be sent to HDC for forwarding within three weeks of the date of
139. A copy of the final report with details identifying the
parties removed, except the expert who advised on this case and
WDHB, will be sent to the Medical Council of New Zealand, DHB
Shared Services, and the Health Quality & Safety Commission,
and placed on the Health and Disability Commissioner website,
www.hdc.org.nz, for educational purposes.
Appendix A: Independent advice
from Dr Patrick Alley
The following expert advice was obtained from Dr Patrick Alley,
a vocationally registered general surgeon:
"My name is Patrick Geoffrey Alley. I am a vocationally
registered general surgeon. I qualified MBChB from the University
of Otago in 1967 and was awarded fellowship of the Royal
Australasian College of Surgeons in 1973. I have spent most of my
professional life in clinical elective and acute general surgery,
teaching, medical administration and research. In November of 2015
I retired from my position as Director of Clinical Training at
Waitemata DHB. I am presently clinical director of surgery at
Ormiston hospital in South Auckland and a member of the Southern
Cross National Medical Committee. I am also on the Council of AUT
University. I have formal qualifications in ethics from the
University of Auckland (Diploma in Professional Ethics 1996). I
declare no conflict of interest in this matter.
This lady presented on the 18th of May 2009 to [the public
hospital]. She gave an antecedent history of abdominal pain
particularly in her lower abdomen. Clinical examination and further
investigations concluded that she probably had appendicitis. The
following day 19th May 2009 she underwent a laparoscopic
appendicectomy. However this was too difficult to complete
laparoscopically so the abdomen was opened. The appendix was found
to be acutely inflamed and perforated. It was eventually removed.
She made a surgically slow but steady recovery over the next few
days and was discharged on 22nd May 2009 with no follow up planned.
Her general practitioner (GP) was made aware of her admission and
treatment and that she would not be followed up as an
The initial histology report on 28th of May (six days after her
discharge) confirmed the clinical impression of acute appendicitis.
However, and importantly, in addition to established acute
appendicitis, the report also defined a carcinoid of the appendix.
This was subject to further evaluation in the histology department.
Special immunochemical stains confirmed a 7 mm adeno-carcinoid of
the appendix. This diagnosis was confirmed on 3rd June 2009.
Although the reports were seen and signed by unidentified Resident
Medical Officers (RMOs) they did not escalate this information to
the supervising consultant who remained unaware of the true nature
of the pathology until a complaint was registered with the Health
and Disability Commissioner's office four years after the
appendicectomy. Neither was information about this tumour
transmitted to the patient. There is a communication from the
supervising surgeon on this matter to which I will allude
An addendum to this report describes the characterisation of
this tumour, its incidence and some of its behaviour.
She remained well until [Month1] when she reported to her GP
with an eight month history of low pelvic pain. A letter was sent
to the general surgical outpatient's clinic at Waikato DHB asking
for a surgical opinion. She was graded to be seen in 2 to 6 months.
However her symptoms worsened, she began to lose weight and she
I am uncertain whether this deterioration prompted a more urgent
review but she was seen by a general surgeon on 27 [Month5]. He had
the benefit of a prior pelvic ultrasound. He elicited a history
which emphasised a potential gynaecological element to her symptoms
but no reference is made to the appendix pathology of three years
previously. She was then referred to the gynaecology department. No
follow-up in general surgical outpatients was arranged.
On 7th [Month7] she had another ultrasound which showed
enlargement of the left ovary and a number of gynaecological
diagnoses were postulated. Because of the history and the findings
on ultrasound [Dr D] referred her to gynaecology
Between [Month8] and [Month13] she attended gynaecology
outpatients on a number of occasions to elucidate both the
questions raised by the [Month7] ultrasound (and the diagnoses
postulated by that examination) and to address her decline in
health. An MRI scan ordered in [Month8] appears not to have been
done until 4th [Month12]. Part of this report states '… diffuse
abnormality in the pelvis … changes can be explained by
endometriosis a superadded malignancy cannot be ruled out'. This
signal went unnoticed and her previous pathology was not reviewed.
Surprisingly, Waikato DHB postulated that because the changes were
most likely gynaecological no review of the appendix pathology was
indicated. Throughout this time she experienced further weight loss
with diarrhoea and vomiting and anorexia.
These symptoms precipitated an admission on 8th [Month13] and a
further CT scan was done on 12th [Month13]. This showed ascites
(intraperitoneal fluid) and a hydro-nephrosis of the left kidney
(in simple terms a blockage of the ureter leading from the kidney
to the bladder). The radiologist's report in part reads '… no
convincing evidence of distant disease is seen to suggest
malignancy …'. On 16 [Month13] this report was amended to give a
contrary view '… suspicious for malignancy and atypical for
endometriosis …' is a phrase from that report.
A gynaecology multidisciplinary team meeting (MDM) on 16th
[Month13] concluded that she be referred to the gastrointestinal
MDM and that a peritoneal tap be arranged. This was done but showed
only atypical epithelial cells. It appears that [Dr F], the
gynaecologist, also asked for a general surgical opinion. As part
of this consultation she had a preliminary consultation with a
surgical registrar who on 19th [Month13] discovered the past
history of appendiceal adeno-carcinoid tumour. However no mention
of this important step in the process was made in the discharge
summary of 19th [Month13] and the patient was not informed about
the missed diagnosis.
At the gastrointestinal MDM on 24th [Month13] her previous
history of adeno-carcinoid was finally discussed in an open forum
and thereafter her care was directed to the general surgical
department. On 30th [Month13] multiple rectal polyps were found at
a colonoscopy. They were excised and histology showed no
She was seen by a general surgeon on the 14th of [Month14]. He
found the previous histology. She had a staging laparoscopy and
biopsies the following day. This confirmed the presence of
metastatic disease involving the peritoneum. Biopsies showed a
tumour consistent with adeno-carcinoid of the appendix.
At this stage the patient and her family were finally told the
whole story. Up until this time they believed she was suffering
from endometriosis. She underwent a course of chemotherapy but
sadly did not survive and died […].
You have asked a number of questions which I will now address.
Many of these questions are about the timeliness of the
interventions by gynaecology and general surgical services. As a
prelude to most of the questions it is important to recognise that
up until [Month14] decisions were being made without the knowledge
that she had had a significant appendiceal tumour in 2009. The
principal error is that failure to recognise the early pathology.
So one could prefix some of the questions with the statement 'Had
clinicians been aware of the true diagnosis was this a reasonable
course of action?' Or the prefix could be 'In the normal course of
events (without a previous diagnosis of adeno-carcinoid of the
appendix) was this a reasonable course?' I have attempted to make
this distinction in some of the questions.
Please comment on the adequacy of [WDHB's] systems in place
(2009) at the time regarding acknowledgement of test results.
At this time seven years ago the normal course of action was for
junior medical staff to receive these results and sign them off.
The major defects inherent in this system include at least the
• It assumes clinical knowledge by relatively junior
practitioners about the significance of certain results.
• There appeared to be no compunction on those staff to alert
their seniors in regard to any abnormal results.
• Whoever signed off this result was not able to be identified.
1. Please comment on the adequacy of [WDHB's] systems in place
at the time regarding escalation of abnormal results to the
It is clear that there was no system operating at that time
which required staff to escalate information to their seniors. It
is entirely dependent on the criteria stated in answer to question
This failure by an unidentified RMO to escalate the result of
the histology on the appendix is the primary root cause of this
serious adverse event.
2. Please comment on the adequacy of [WDHB's] proposed changes
following these events.
[WDHB] - as many other DHBs have done - have introduced a formal
acknowledgment process for all results of tests and imaging done on
their patients. As far as I can see these processes are aligned to
other DHBs and there is - fortunately - little contemporary
evidence of adverse events resulting from incorrect interpretation
or non-acknowledgement of results. The system seems robust.
3. Please comment on the adequacy of [Dr B]'s care of [Mrs A]
including but not limited to:
• Her expectation that junior staff members would bring abnormal
test results to her attention.
• Her process of not personally following up on all test
I feel some sympathy for [Dr B]'s position in that she was not
made aware of the histology report. However, as is always the case,
the ultimate responsibility for patient care rests with the
consultant in charge of the case, in this case [Dr B]. It is
an insufficient response to say that there was an expectation that
junior staff should draw her attention to abnormal results. It was
she who removed the appendix after all. Interestingly in 2014
[WDHB] changed the modus of acknowledging reports and essentially
they formalised what had been standard and traditional specialist
behaviour in regard to that process. The relevant quote is: 'SMOs
are ultimately responsible for the management of patients in
hospital under their care or seen in clinic under their name.
Having responsibility for patients includes taking responsibility
for acknowledging results and (the) actions required after tests
performed on their patients'. In my view this failure to
follow up a histology result is an accessory fact to the primary
cause of non-escalation by the RMO.
4. Any other issues that you think require comment regarding the
relevant systems in place regarding the standard of care provided
to [Mrs A] in 2009.
The simple fact of the matter is that a significant abnormality
in a histological specimen was not reported to the people who could
have made a difference to the outcome. From a surgical viewpoint
one cannot know for certain what action might have been taken. The
options would include a programme of surveillance with regular
tumour marker assay. Or more likely given the uncertain prognosis
with this type of tumour she would have gone on to a right
hemi-colectomy with a very high chance of cure.
However the surgical management is not the most important
deficit occasioned by this lapse. The significant effect is that
the patient remained unaware of a potentially lethal tumour until
very late in the story when metastases had supervened. She was thus
denied any say in her management and her autonomy severely
Standard of care in 2012-2013
5. Whether general surgeon [Dr D]'s standard of care was
appropriate including but not limited to the following:
• Concluding [Mrs A]'s symptoms were mostly likely
Given that [Mrs A] complained of pelvic pain and this pain was
related to her periods then it is not an unreasonable proposition
that her symptoms were gynaecological. In the event the symptoms
were truly gynaecological, but sadly as a result of a metastasis to
her ovaries. I note a comment (I presume from an unidentified
general surgeon) that metastasis to the ovary is a rare event in
this condition. This is wrong. My review of the literature shows
convincingly that the ovary is a prime site for metastasis of
adenoid carcinoma of the appendix. I include a quote from one of
many references. His view would have been strengthened by the
imaging which implicated the pelvis and ovary in a disease
• Not carrying out a colonoscopy.
I would not regard this as a departure from normal practice,
given the history that was elicited. This had distinct implications
for a gynaecological cause for her pain. Had he been aware of her
past history then colonoscopy might have had more priority. I do
note the eventual colonoscopy was normal.
• Not reviewing appendix pathology from 2009.
This clearly is a significant lapse in clinical performance.
Given that the fundamental error in the management of this case was
the non-recognition of adeno-carcinoid of the appendix, then by
this time the lesion had undergone a metastasis. Hence, it is
debatable whether review of the appendix pathology in 2012 made any
material difference to the outcome. However, it is significant that
failure to review the histology of 2009 did not alert [Dr D] to the
potential for metastatic disease of adeno-carcinoid of the appendix
to be causing [Mrs A]'s symptoms. This in effect contributed to a
six month delay in securing a diagnosis. Also as previously
mentioned it denied [Mrs A] any say in her management.
6. The adequacy of [Mrs A]'s grading for gynaecological review
and the time spent waiting for an MRI.
The gynaecologists managed this patient as though she was a de
novo presentation and were unaware of her past history. As the
introduction to these questions points out, this is a question that
should be prefaced (in my view) by the statement: 'in the normal
course of events'. Given that rider she was seen at an appropriate
time. I believe it was the fault of the general surgeons in not
researching her notes and defining the true nature of her
appendiceal pathology. The delay in getting the MRI done is
significant and is independent of what [Mrs A]'s history was. A
four month delay for an MRI in a patient with these symptoms is
7. Whether it was acceptable for [obstetrician/gynaecologist]
[Dr F] to audit a general surgery review but not expect it to be
followed up by the gynaecological team.
It was clear at this stage that whatever the pathology within
[Mrs A]'s abdomen it was not appropriate for further gynaecological
investigation and it is acceptable that the patient was referred
back to general surgery.
8. Whether it was acceptable that the previous appendiceal
carcinoid finding discovered in 19 [Month13] was according to
[WDHB] not identified at this time as a missed diagnostic error
because it was not known by clinicians that the [pathology] result
had not been followed up in 2009 and therefore was referred for a
new investigation as a possible recurrence.
There is an internal inconsistency in this question. It is not
possible to cite a recurrence of a problem that has neither been
treated or that is not in the consciousness of the clinicians
caring for the patient. I have not found in the clinical records
any allusions to the word 'recurrence' so I presume this is a
statement from the Waikato DHB management. It is disingenuous and
erroneous in that it implies a lesser lapse in clinical management
than the more correct appellation for the event namely a missed
9. Whether it was acceptable that possible 'recurrence' was not
communicated to [Mrs A] 'until further investigations were
The use of the word 'recurrence' is inappropriate. Therefore it
should not have been communicated to [Mrs A]. Recurrence implies
that treatment had been offered. No such treatment occurred for
[Mrs A]'s adenoid carcinoma. The lack of communication is at two
levels. As mentioned in this answer the use of the term recurrence
should not have been communicated to [Mrs A] but the missed
diagnosis should have been. Dr H (see later) was aware of this
missed diagnosis but reasonably could not communicate until the
definitive pathology from the laparoscopy on 26 [Month14].
10. Whether it was acceptable that prior to 26 [Month14] no
other diagnoses including possible malignancy had been discussed
with [Mrs A] other than endometriosis (see later).
It was clear from the laparoscopic findings that metastatic
disease was known but the source was not. We know in hindsight that
the most likely cause of this was the appendiceal carcinoid but at
that time it could well have been a metastatic ovarian carcinoma
for example. If it were the latter then there would have been an
entirely different course of treatment. When it was realised that
it was consistent with the missed diagnosis in 2009 then [Mrs A]
was informed appropriately in my view.
11. The appropriateness of [Dr H's] response that he waited for
the formal pathology for the biopsy available on 26 [Month14] until
informing [Mrs A] of her prognosis.
Early in his clinical management of [Mrs A] [Dr H] was aware
that a significant missed diagnosis had occurred. Therefore he was,
in my view appropriately cautious in waiting for a firm
histological diagnosis to be sustained. While metastatic disease
from the missed adenoid carcinoma was very likely it could not be
absolutely confirmed until the histology was available.
12. Whether it was appropriate that [Mrs A] was not informed of
the missed appendix pathology until 28 [Month14].
Obviously this is a very important aspect of the case in that
the patient was not informed of that misdiagnosis until 28
[Month14]. As always, earliest is best and [WDHB] should have
conceded their error earlier than they did.
13. Any other comments you wish to make regarding [Dr H's] care
of [Mrs A].
14. The adequacy of [WDHB's] policy in place at the time
regarding open disclosure and whether it was followed appropriately
in this case.
There is some mitigation in the sense that the pathology was
uncertain, but there was delayed open disclosure. This raises
another issue however. I have found an increasing number of DHBs
have robust policies on open disclosure but their effectiveness
remains uncertain. In this case I would be interested to know
whether the DHB circulated their staff to the effect that there had
been an absence of open disclosure and secondly whether it is
possible to audit open disclosure by a random sampling of patients.
I agree this can be consumptive of resource but it would be
reassuring (particularly to the DHB) to know that the system
15. Any other comments regarding the adequacy of [WDHB's]
systems in place during 2012 and 2013 relevant to the standard of
care provided to [Mrs A].
Subsequent to the communication from the Health & Disability
Commissioner's office, I asked whether there were regular
surgical/pathology meetings in [WDHB]. In 2009 there were not
and I was somewhat surprised to hear that, apart from the
colorectal service, that is still not the case. Had such meetings
been held in 2009 this whole saga would not have unfolded the way
it did. The normal course of events is that unusual or rare cases
disclosed on histological examination of surgical specimens are
discussed in a forum including surgeons and pathologists. Given the
good reputation as a teaching institution, [WDHB] appears not to
have used this very important teaching resource and my strongest
urgings to that District Health Board is that they institute such
The primary error was the failure of an unidentified RMO to
escalate an abnormal pathology result to their seniors.
The secondary errors were
• The failure of the supervising consultant to see the histology
• The failure of the general surgeon who saw her in [Month5] to
ascertain her past pathology of May 2009
• Failure of open disclosure
• The four month delay in securing an MRI
The primary error was a severe departure from normal clinical
The secondary errors are moderate departures from normal
Cancer. 1978 Dec; 42(6):2781-93. Adenocarcinoid, a
mucin-producing carcinoid tumour of the appendix: a study of 39
cases. Warkel RL et al.
Adenocarcinoid is a form of appendiceal carcinoid possessing
features of both carcinoid and adenocarcinoma. There are two
histologic types. Thirty patients had the goblet cell type,
characterized by nests of large mucin-distended cells. Nine
patients had the tubular type, characterized by small glandular
structures lined by uniform cells. Despite abundant mucin and a
goblet cell or acinar-like arrangement, a closer relationship to
carcinoid than to adenocarcinoma is suggested by a concentration of
tumour elements below the crypts of Lieberkuhn, a lack of evidence
of neoplastic transformation of the appendiceal mucosa, and the
demonstration of argentaffin or argyrophil granules in 88% of the
lesions. Six tumors, all of the goblet cell type, metastasized and
resulted in the death of the patients. One of the tumours that
metastasized had a prominent tubular component. Most
adenocarcinoids can be adequately treated by appendectomy, but
hemicolectomy is recommended for those tumours showing atypical
foci, a high mitotic count, or spread beyond the appendix.
Semin Diagn Pathol. 2004 May; 21(2):134-50. Pseudomyxoma
peritonei and selected other aspects of the spread of appendiceal
neoplasms. Young RH1.
High-grade adenocarcinoma of the appendix may spread to the
omentum and peritoneal surfaces without grossly striking mucin
deposition and resemble spread of other high-grade gastrointestinal
adenocarcinomas. In many cases in females there is involvement of
one, or more often, both ovaries. (my emboldening)."
Further comment was made by Dr Alley on 6 June 2016:
"In essence the diagnosis was missed at the first operation.
That is the root cause of the patient's difficulty. A secondary
error was the failure to review her pathology at her presentation
four years later. [Dr D] cites (correctly) the life time risk of
appendicectomy and seems to be saying that its commonness precludes
checking previous pathology. He somewhat surprisingly says that
previous appendiceal pathology is never checked saying … 'It is not
normal clinical practice in the outpatient setting to check old
histology reports as finding a cancer missed from an earlier error
is an extraordinarily rare even.' It is unclear whether this is a
DHB policy or his personal preference. I suspect the latter. I also
note that it was a relatively straightforward matter for [Dr H] to
find and consider the previous histology so I wonder what the
standard practice really is in this DHB in regard to checking such
I would be very surprised if either of these surgeons took their
stated positions in the company of a group of specialist surgical
peers - for example in a case presentation I can imagine the
negative response to a comment such as 'In a patient presenting
with pelvic pathology it is unhelpful to review the histology of a
previously removed appendix'.
Another test of the circumstance is to consider the response of
a candidate for the final FRACS exam who said previous appendiceal
pathology in such a presentation would not be relevant. I can tell
you any examiner would have a very dim view of such a response.
Turning to [WDHB's] submission, [this] affirms the good standing
of [Dr D] and reiterates [earlier correspondence]. [The] account of
the patient's presentation is somewhat incomplete. I agree that the
patient came with a story of abdominal pain but on examination [Dr
D] found a suspicion of an abdominal mass and a likely pelvic mass
on rectal examination. Surely, I contend, these additional findings
would be a stimulus to review any previous pathology. [WDHB] does
not address this point.
I also am very concerned that [WDHB] claims the outpatients
'slots' are only ten minutes for patients. This is a ridiculously
short amount of time to elucidate a complex problem such as that
presented by [Mrs A]. The DHB should be asked to confirm this
allocation of time for new patients. If [this] is correct then it
is only a matter of time before a similar error occurs.
[WDHB] should also be reminded that 'busy-ness' of doctors in
practice is no defence for an error. I can easily forward to [WDHB]
judgments that were particularly harsh on medical staff who pleaded
this in mitigation of an adverse clinical event.
In summary the two submissions have not altered my view that an
error occurred in [Dr D] not reviewing the previous histology
particularly in the light of his clinical findings. Furthermore, I
remain of the view that it is an error of moderate significance. I
am grateful for the response however because it has raised an issue
(the time allocated for new patients to be seen in clinics) of
which I was unaware. As always I would be pleased to see further
submissions on my analysis of this case."