A woman in her 60s wants a face-to-face apology after her bowel cancer went undiagnosed, despite multiple trips to her local emergency department.

The woman went to the emergency department [ED] three times in as many months with rectal bleeding, but her cancer went undiagnosed, a decision by the Health and Disability Commissioner [HDC] said.

The report, released today, focused on the importance of assessing patients when they go to hospital multiple times with the same symptoms, making a number of recommendations around adequate examinations and care of patients facing issues such as the woman.

Referred to as Mrs A, the woman told the HDC she had experienced 10 years of excellent treatment at the public hospital, but the events she complained about had an impact on her trust in the system.

At the time she was undergoing chemotherapy through the Southern District Health Board for relapsed lymphoma.

As a result of the delay, she had to have surgery to attach a stoma bag, which is now irreversible due to a relapse in her lymphatic cancer.

In the space of just three months, she was seen three times with rectal bleeding after going to ED, but it took an emergency referral from her GP to a private practice, after recording and "irregularity" in January 2019 to finally get answers.

This was the day after she was dismissed by Southern DHB which said it would not be investigating her symptoms further because of "normal" test results.

Of the three times she went to ED, the first in November 2018, the second in December 2018 and the third in January 2019, she was admitted to the haematology ward twice.

On her first visit in November a general surgery registrar performed a rigid sigmoidoscopy, a test to check the lower part of the colon and intestine, but results were inconclusive because of the amount of blood.

All three times she was examined and "no masses were recorded".

Despite a referral on January 22 from a haematology consultant to the gastroenterology team to consider a colonoscopy, the woman was told three days later they would not look into her case.

This was just over two weeks before she was diagnosed with bowel cancer.

She went to the GP the day after she was told the DHB wouldn't be investigating further.

A private surgeon then assessed her on February 8 and found a "significant mass on the rectal wall", and soon after she received the cancer diagnosis.

Health and Disability Commissioner Morag McDowell said there were multiple lapses in care for the woman, including no follow-ups to identify why the bleeding was happening, nor to the inconclusive tests, one of which was recorded inaccurately in her discharge summary.

McDowell also said the woman's family history of bowel cancer was not explored by any of the clinicians during her three visits to ED.

McDowell found SDHB failed to provide services to the woman with reasonable care and skill.

"There were numerous missed opportunities by a number of SDHB clinicians across several presentations to assess Mrs A's presentation critically and co-ordinate the appropriate investigations, which had they been performed, would more likely than not have identified Mrs A's rectal cancer," she said.

"I consider that the cumulative effect of these factors and missed opportunities demonstrates a clear pattern of poor care, attributable to SDHB as the overall service provider."

The SDHB said it deeply regretted what happened in Mrs A's case and accepted that it failed to identify the cancer.

Had further investigation been done at the time, either by direct vision or contrast studies, the lesion would have been identified, it added.

"SDHB has advised Mrs A that as a result of concerns around the processes for colonoscopy referrals, the DHB is undertaking a full review of its processes to ensure that referrals for colonoscopy are handled in a more timely and transparent manner," McDowell said.

She also ordered the SDHB to make a face-to-face apology to Mrs A.