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GP Breaches Code For Not Following Up On Ultrasound

In a report released today, the Health and Disability Commissioner has found a GP breached the Code of Health and Disability Services Consumers’ Rights (the Code) for not following up with a patient he had referred for an ultrasound.

The woman, in her sixties at the time, attended a consultation with her GP after experiencing post-menstrual bleeding. The GP documented that the woman had experienced some bleeding over the past few days that was not associated with any pain and provided her with a voucher for an ultrasound scan.

However, following the consultation the woman did not undergo the ultrasound scan, as she had the impression from the consultation that the bleeding was nothing to be concerned about and that the scan was optional. Approximately a year later, the woman developed accompanying abdominal pain, and, sadly, was diagnosed with stage 4 endometrial cancer.

In her report, Deputy Commissioner Deborah James accepted that the GP had followed the appropriate Community Health Pathway by advising the woman to undertake an ultrasound prior to undertaking any further investigation.

However, given this was to be self-initiated, Ms James was critical that, in light of the risk of endometrial cancer, the GP did not follow up with the woman to ensure she had undergone the scan. She found the GP did not provide the woman with service of an appropriate standard and was in breach of Right 4 of the Code which gives consumers the right to an appropriate standard of care | Tautikanga.

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Ms James also made an adverse comment about the medical centre for deficiencies in its policies for tracking referrals made through the voucher system. Since the events, the centre has updated its process for the voucher system, which includes that a manual task reminder must be set every time a clinician refers a patient for an ultrasound scan.

Ms James recommended the GP provide an apology to the woman and undergo training in therapeutic communication with patients, should he return to practice.

She also recommended the medical centre undertake an audit of all voucher referrals to ensure that task reminders have been made by clinicians and develop an education session for staff using an anonymised version of the HDC report.

Editors notes

Please only use the photo provided with this media release. For any questions about the photo, please contact the communications team.

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

Names have been removed from the report to protect privacy of the individuals involved in this case.

The Commissioner will usually name providers and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. More information for the media, including HDC’s naming policy and why we don't comment on complaints, can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

In 2022/23 HDC made 592 quality improvement recommendations to individual complaints and we have a high compliance rate of around 96%.

Read our latest Annual Report 2023

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