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Those whose eyes have not glazed over during ongoing coverage of the Southern District Health Board’s management of colorectal cancer diagnosis would have been shocked by a Health and Disability Commissioner report released last week.

It involved a man, in his 50s, from a community residential mental health service who turned up at the Emergency Department (whether it was Dunedin or Invercargill is unspecified) seven times in two months in 2019 with abdominal pain. The diagnosis was that he had constipation caused by antipsychotic medication. Investigations such as CT colonography or colonoscopy were not undertaken, despite little improvement in his condition and in the presence of ‘‘ red flag’’ symptoms.

He was admitted four times as an inpatient to general surgery, each time under the care of a different consultant.

When he eventually underwent surgery, he was found to have widespread colon cancer which had caused a complete bowel obstruction, and later died of septic shock.

Deputy Health and Disability Commissioner Vanessa Caldwell, after investigating a complaint from the residential mental health service, found both the board and a consultant general surgeon (no longer working in New Zealand) had breached the man’s right to services provided with reasonable care and skill.

Her report acknowledged that the man’s diagnosis was not straightforward.

The issue was not the failure to diagnose the cancer earlier, but failure to investigate the patient’s symptoms fully and consider an alternative diagnosis after multiple presentations with no improvement.

It highlighted the importance of critically assessing patients who presented on multiple occasions with the same symptoms within a relatively short period of time, she said.

The consultant surgeon found to have breached the Health and Disability Code, called Dr B in the report, told the HDC at the time of the events he was new to New Zealand and traditions of care were quite different from what he was used to. He would have arranged for an inpatient colonoscopy which was always available in his home country, but this was not the case at SDHB.

‘‘The imposition of a breach leaves me with the impression of being singled out for what was an issue involving many consultants and systemic issues.’’

Another consultant said it was unfortunate Dr B had been singled out, recalling Dr B saying he had found it almost impossible to get inpatient colonoscopy approved in the public hospital.

Dr Caldwell acknowledged the stated access issues for the service but considered this should not be a reason for not making an appropriate referral. In not making the referral, Dr B himself, who had disregarded the patient’s abnormal CT scan, made the decision for the service not to be available for the patient.

As well as individual accountability for the decisions made, Dr Caldwell considered the system let the patient down.

She took the serious step of referring the DHB to the director of proceedings to see if any legal action should be taken. (In recent years, such referrals have been rare — nine out of 133 HDC investigations in 2019-20, nine from 102 in 2018-19, nine (involving 11 providers) in 2017-18, for example.)

The DHB, which has apologised for its shortcomings, told the HDC the context of the care was important and that the many improvements it has made since this case meant the referral was disproportionate to the failings.

After contemplating the whole of the HDC report of this distressing case, I find that view tin-eared.

I was fascinated to read in the report that the DHB said it had reviewed acute bowel presentations, although Dr Caldwell did not elaborate further.

In May last year I embarked on a tortuous process seeking the number of major bowel cancer surgeries done acutely at SDHB for the years 2013 to 2020. I wanted to know if there was analysis of whether such patients had previously been denied a colonoscopy or were waiting for one because it might shed more light on the impact of access rationing.

I was eventually told providing such information would involve an arduous and costly process more suited to a research project, but that from 2021 such information has been gathered.

No response has been received to my question asking if the DHB has considered proactively encouraging research into the 2013-20 time.

After following the colonoscopy access issues in Otago and Southland for more than a decade now, I wonder how often over those years clinicians might have avoided asking for colonoscopies or CT colonography because they considered it futile.

Also, how many patients never complain because they do not have family or others who can advocate for them, or they just get tired?

The board’s attempt to minimise the significance of its failings in this case, and its reluctance to thoroughly investigate earlier concerns, make me worry this saga is not over yet.

 - Elspeth McLean is a Dunedin writer.