A woman with a high risk of developing liver cancer died of the disease after she wasn’t given the surveillance scans her doctor ordered.

A new system for repeat referrals was adopted by Health New Zealand Te Whatu Ora in 2019, but the woman’s surveillance scans weren’t carried over to the new system.

A further unrelated error in the outpatient department meant a follow-up with her specialist, which could have detected that she wasn’t getting her recommended scans, also wasn’t booked.

The woman’s son complained to the Health and Disability Commissioner (HDC) who found that Health NZ’s system was “deficient” as it failed to continue the surveillance scans.

The woman had been identified as having a high risk of developing liver cancer after she was diagnosed with a liver condition in 2011.

A gastroenterologist had met with the woman and, in 2017, six-monthly surveillance liver ultrasound scans were requested, along with follow-up gastroenterology appointments afterwards.

In 2018, the gastroenterologist referred her for an MRI (magnetic resonance imaging) scan of her liver as her most recent surveillance ultrasound had raised concerns. While no mass had been found, a further MRI in 12 months was suggested.

However, the woman’s surveillance scans stopped in 2019.

A new radiology referral system was put in place which did not accept repeated or recurring requests - including follow-up liver surveillance ultrasound scans.

Future scans required a new referral for each scan.

HDC Deputy Commissioner Dr Vanessa Caldwell said there were a lack of “appropriate safety-nets” in place to pick up patients already in the system for pre-scheduled appointments.

“A system change requires a certain amount of forethought about the risks posed and how to mitigate them.

“When it was determined that surveillance ultrasound scans would require a new referral, there appears to have been no consideration as to how this might pose a risk to patients requiring new referrals for repeat scans to be generated, and how to mitigate this.”

The woman had been referred to the ED by her GP in late 2022, as she’d been experiencing nausea, fatigue, reduced appetite and back pain.

A CT scan found she had advanced liver cancer and she received palliative care until she died.

She’d attended hospital for other reasons between 2019 and 2022, but there had been no concern about her liver during that time, and other specialists she’d seen hadn’t considered whether she was due for a liver follow-up.

Health NZ’s reason for the referral systems change, as cited by the HDC report, was “surveillance referrals can cause there to be an assumption that there has been no change in the patient’s presentation between scans, or radiology does not receive appropriate updates about a patient’s current status, which comes with a clinical risk.”

There were also impacts on scheduling, as repeat appointments often weren’t cancelled in cases where a patient’s circumstances had changed.

The HDC report found that while the reasons for a system change might be valid, there hadn’t been checks to determine that those already on surveillance schedules weren’t missed.

“In the context of a stretched resource in gastroenterology, I consider that it was not the sole responsibility of the referrer (in this case, the gastroenterologist) to make new referrals for all patients under surveillance,” Caldwell said.

She said there should have been a message sent to GPs about the change, too.

Health NZ had suggested to the HDC in its response to the investigation that the woman’s GP had failed to pick up on the fact that the surveillance scans weren’t being done, and this had led to the delay in her diagnosis.

“There is no evidence that the GP was requested to undertake a monitoring role in this situation. Further, there is no evidence that the GP was made aware of the system change.”

The HDC was critical of the communication by Health NZ to staff, as an email sent hadn’t been sufficient to explain whose responsibility it was to make new referrals.

A further failing by Health NZ in this woman’s case had been the missed follow-up outpatient appointment with the gastroenterologist - it was not booked due to a process error in the Outpatients Appointment Office.

Had that been booked, the specialist might have picked up that the woman wasn’t getting her regular surveillance scans; the further recommended MRI follow-up could also have been booked.

The HDC report said that while “ultimately earlier detection may not have resulted in a different outcome for [the woman] it would likely have allowed her time to accept the diagnosis and spend more time as she would have wanted.”

Since the HDC investigation, Health NZ Te Whatu Ora has indicated it will increase communication to GPs regarding liver ultrasound scans, complete an audit of the liver cirrhosis surveillance programme to ensure that no other surveillance patients have been missed.

It would also apologise to the woman’s family for the delay in her cancer diagnosis.

Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.