Community Scoop » Missed Opportunities in Cancer Patient Care

Press Release – Office of the Health and Disability Commissioner

A man in his 50s had a history of schizophrenia and chronic thought disorders and lived in a community residential mental health service. Over a six-week period, he presented to the emergency department seven times with severe abdominal pain. …

A man in his 50s had a history of schizophrenia and chronic thought disorders and lived in a community residential mental health service. Over a six-week period, he presented to the emergency department seven times with severe abdominal pain. He has been repeatedly diagnosed with constipation due to an antipsychotic drug (clozapine).

With each presentation, the man’s diagnosis remained the same, despite the lack of improvement and other red flags that something else might be causing his pain. Each staff member did not question the previous diagnosis or undertake further investigations until they underwent surgery to examine the abdomen.

During the operation, the man was found to have generalized colon cancer with tumors causing complete bowel obstruction. Sadly, the man died of septic shock, secondary to metastatic colon cancer.

The Deputy Commissioner felt that there had been many missed opportunities by many SDHB clinicians, through multiple presentations, to further investigate the man’s symptoms and reconsider his diagnosis when he did not s is not improved.

“The cumulative effect of these missed opportunities demonstrates a disturbing lack of critical thinking and acceptance of the male’s unimproved condition by SDHB staff, attributable to DHB as an overall service provider,” said Dr Caldwell.

“I acknowledge that the man’s disease was metastatic and that a previous diagnosis did not influence the final outcome. However, I note that an earlier diagnosis of colon cancer could have opened up opportunities for palliative care that could have led to a very different end of life for this man.

The full report for Case 19HDC01214 is available on the HDC website.

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About Antoine L. Cassell

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