A woman fast-tracked through the medical system as a “suspected cancer patient” was told she probably didn’t have cancer before the disease killed her.
A report out from Health and Disability Commissioner Morag McDowell on Monday recommended the Wairarapa and Hutt Valley health boards send written apologies to the woman’s husband, who raised the complaint about her care being mishandled. They have also been told to make changes to stop repeat incidents.
The woman and her husband’s name have been redacted in the findings, which show she went to her GP in October 2018 with a painful lump in her left breast. She was referred to the Wairarapa DHB as a “fast-track suspected cancer patient”.
Mr A told the commissioner his wife contacted the Hutt Valley DHB three times in five days and was refused an appointment because it was “just an infection”. Health board records show it made her a booking for November 1.
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Her condition worsened and three days later she saw another GP, who ordered an urgent ultrasound on the breast, which happened the same day. After the scan she went to the Wairarapa emergency department, where the discharge noted “not a high suspicion of cancer”.
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A woman has died from cancer after being misdiagnosed. (File photo)
A scan showed a large mass – suspected as being cancer – and she was referred for an urgent assessment. The woman was given a biopsy in Hutt Valley on November 1 and a note between surgeons said there was “no clinical doubt this is cancer”.
Following the biopsy, she had pain and other symptoms, sending her back to her GP, emergency department and specialist surgeons numerous times over the next two months.
It was on November 12 – almost two weeks after the biopsy and as she continued to have symptoms – before a meeting of 10 Hutt Valley medical staff, including four consultant specialists, decided “Ms A did not have cancer, but had plasma cell mastitis”.
Plasma cell mastitis is described in online medical references as benign.
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It was months before the woman’s suspicions – that she had cancer – were confirmed. (File photo)
Mr A told the commissioner his wife had looked into her symptoms and thought her pain was associated with inflammatory breast cancer.
She went back to doctors a few times in the coming weeks and ended up getting a second biopsy.
It was January 9, 2019 when those biopsy results came through showing she likely had inflammatory breast cancer. She was initially told it was a stage three and treatable but a scan on January 15 showed it was terminal.
She died later in 2019.
McDowell concluded the Hutt Valley health board failed the woman by accepting the plasma cell mastisis “without questioning” the unusual results.
“The system in place between [the two health boards] for the delivery of specialist breast services was fragmented and disjointed,” McDowell said.
But she was encouraged to see changes had been made at both boards as a result.
Both Hutt Valley and Wairarapa health boards fully accepted the commissioner’s findings and were committed to implementing her recommendations.
“We acknowledge that we failed our patient and their whānau, and we are grateful for the time the family has taken to communicate with us,” the chief medical officer for Hutt Valley DHB John Tait said.
All recommendations were being addressed and a letter of apology had been sent to the woman’s family, Tait said.
“We would like to take this opportunity to express our condolences and sincere apologies to the patient’s whānau,” Wairarapa DHB chief medical officer Dr Mark Beehre said.
