Dual DHB Service Leads To Delay In Diagnosis Of Breast Cancer

Health and Disability Commissioner Morag McDowell today released a report finding two district health boards (DHBs) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code), for failures that led to a delay in diagnosing a woman with breast cancer.

The woman’s local DHB, Wairarapa District Health Board (WDHB), does not have a permanent breast specialist surgeon, so patients are referred to Hutt Valley District Health Board (HVDHB) for breast imaging and interventional procedures.

In 2018, the woman, who was in her forties, developed a painful lump in her breast that her doctors considered was likely to be breast cancer. She underwent imaging which indicated a suspicion of cancer, but a biopsy came back negative. A multidisciplinary team at HVDHB diagnosed her with plasma cell mastitis on the basis of the biopsy result. The woman’s condition deteriorated and eventually a further biopsy was undertaken (more than two months after her initial presentation), that showed inflammatory breast cancer. The cancer was aggressive and the woman sadly passed away in 2019.

Ms McDowell was critical of HVDHB for diagnosing the woman with plasma cell mastitis, without questioning the biopsy result which did not accord with the imaging results, and that further imaging and biopsy was not recommended.

The lack of a single clinician in charge of the woman’s care contributed to the lack of recognition that this was not plasma cell mastitis. The frequent change in clinicians made it difficult for any clinician to have a full picture of the progression of the woman’s condition

"Due to multiple clinicians involved, the woman’s care was affected by the lack of clarity as to which DHB and clinician had overall responsibility for her.

"Under the Code, consumers have the right to co-operation among providers to ensure quality and continuity of services, and therefore I have found that both DHBs are equally responsible for the delay in her diagnosis," said Ms McDowell.

Ms McDowell also considered the lack of a clinical alert once the correct diagnosis was available was a critical error, and that WDHB should have a system to "red flag" abnormal results to clinicians.

"WDHB had the information needed to make an accurate diagnosis and provide the woman with appropriate care, yet its system failed to ensure that the information reached the appropriate clinicians within an appropriate time.

"This contributed to an unnecessary delay for diagnostic results in a time-critical situation. It is vital that DHBs have systems in place for alerting clinicians to abnormal test results," said Ms McDowell.

Ms McDowell recommended that WDHB and HVDHB provide an update on the changes made in response to these events, and report on any further changes implemented. She also recommended that WDHB and HVDHB provide a written apology to the woman’s husband.

Both DHBs have since made changes to their processes. To augment care continuity, WDHB created a new role to maintain visibility and continue of care for General Surgery patients across the region, and incorporate a red flag system for abnormal results into the upgrade of its patient records system. HVDHB are developing more comprehensive protocols and policies to improve its services and align and facilitate critical discussions with WDHB in the care for breast patient transfer and management.

"It is encouraging that both DHBs have acknowledged the lack of clarity in their breast service and implemented changes to their processes, and put in place a number of initiatives to improve it," said Ms McDowell.

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