Delay In Man’s Throat Cancer Diagnosis

Health and Disability Commissioner Morag McDowell today released a report finding a District Health Board and a speech language therapist in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in their care of a man with throat cancer.

The man, in his mid-sixties, was referred to the Counties Manukau District Health Board’s (CMDHB) Otorhinolaryngology (ORL) service as his voice had become hoarse. Instead of being booked for an appointment with both an ORL clinician and speech language therapist, the man was mistakenly booked with a speech language therapist only.

The therapist performed imaging of the man’s vocal folds and identified an "irregularity". She requested a follow up appointment with an ORL clinician in three months’ time, but no follow up appointment occurred.

The man was not followed up for ten months, at which point he saw his GP who re-referred him. The man was eventually seen by an ORL clinician, almost a year after his appointment with the speech language therapist, and diagnosed with throat cancer.

The Health and Disability Commissioner criticised the speech language therapist’s failure to ensure her imaging report was reviewed by an ORL clinician, as it was outside her scope of practice to diagnose pathology. The Commissioner also considered the therapist should not have identified the timeframe for the man’s follow up appointment without ORL clinician input.

The Commissioner considered that inadequacies in CMDHB’s electronic referral system and speech language therapy clinic processes at the time resulted in an unacceptable delay in the man receiving a diagnosis of his throat cancer. Its booking system was not sufficiently clear to ensure successful communication between clinicians and administrators, clinic policies were unclear about when ORL review was needed, and there was poor orientation for staff on making follow-up appointments.

"This highlights the importance of having in place adequate systems to ensure that consumers receive timely and appropriate services for health concerns that are identified," Ms McDowell said.

The Commissioner noted it is prudent to have a system in place that ensures more serious requests are prioritised over less serious requests.

Ms McDowell recommended that CMDHB report back on the effectiveness of the changes it has implemented since these events, and consider changes it could make to ensure that systems are in place to enable speech language therapists to show their reports of endoscopic examinations to an ORL clinician so that timely and appropriate ORL review can occur when required.

She recommended that CMDHB use this report for staff training on the issues identified. At the Commissioner’s request, CMDHB provided a written apology to the man.

Since these events, the speech language therapist has accepted the need for monthly clinical supervision for a period of 12 months, taken appropriate action to improve her practice, and provided a written apology to the man.

The full report on case 19HDC00437 is available on HDC's website.

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