(file image). Photo: 123RF
Te Whatu Ora Waikato has been asked to apologise to an elderly woman for multiple system failures in the management of her echocardiogram.
The woman, aged in her 70s at the time, experienced significant delays in getting the test done and learning the results, which indicated severe heart valve disease and other heart disease.
Given the delays, she then sought private medical treatment for her heart condition.
The Aged Care Commissioner Carolyn Cooper found Waikato DHB (now Health New Zealand/Te Whatu Ora Waikato) breached the Consumers' Rights code by failing to provide services with reasonable care and skill.
The Commissioner's report said in 2019 the woman was initially referred by her GP to Thames Hospital for an echocardiogram.
The first referral exceeded the recommended timeframe for triage by ten working days, and it then took around six months for the echocardiogram to be performed, which ideally should have been undertaken within six weeks, it said.
In addition, the echocardiogram results were not sent directly to the GP who referred the woman for the test. This resulted in an additional delay in the woman learning of the results and treatment being scheduled.
"I am critical that Health New Zealand did not have a robust referral management pathway at the time of events with the appropriate safety net in place to ensure that patients did not fall through the cracks if a human error occurred," Cooper said.
"Without the woman's active participation in following up her echocardiogram appointment and then result, it is possible that Health New Zealand would not have identified the omissions, which could have caused significant harm to her."
No further systemic investigation was undertaken by Health New Zealand for the errors and delays once they were clear, Cooper said.
"There appears to have been no urgency shown by Health New Zealand for the lack of action taken on the echocardiogram and no escalation for any investigation once Health New Zealand was aware that the woman's significantly abnormal results had not been actioned," she said.
Cooper said since the events, Health New Zealand, the cardiologist and medical centre had made changes to their practice.
These included writing policies for the management of echocardiology referrals and vetting, along with policy for the management of abnormal results, including the process for informing GPs of results.
Te Whatu Ora Waikato said an echocardiogram project manager had been appointed and a working group formed.
The group met every one to two weeks to create and implement strategies to improve the efficiency of services and departmental processes, and to update various services, it said.
Cooper's recommendations included that Te Whatu Ora Waikato provide a written apology to the woman.
