Health and Disability Commissioner Morag McDowell today released a report finding a surgeon in breach of the Code of
Health and Disability Services Consumers’ Rights (the Code) for failures in her care of a woman who was later diagnosed
with breast cancer.
The woman, in her forties at the time of these events, had been diagnosed and treated for breast cancer in 2013.
In 2018, she was found to have a breast lump. The breast and general surgeon performed a biopsy on the lump but failed
to order a mammogram or an ultrasound. The surgeon formed the opinion that the breast lump was benign and discharged the
Five months later, the woman was referred by her GP back to the public hospital. A radiologist performed a series of
ultrasound-guided biopsies and sent samples for testing. This led to a diagnosis of breast cancer and ongoing treatment.
The Commissioner found the surgeon failed to request an ultrasound or a mammogram of the woman’s breast lump, as
specified at the time in the district health board’s (DHB) Breast Clinic Management Protocol.
Ms McDowell said this report "emphasises the importance of complying with DHB protocol and accepted practice when
investigating breast lumps."
The Commissioner recommended that the surgeon conduct an audit of her last 20 assessments of patients where there was
suspicion for a breast lump and report back to HDC on the results, and provide a written apology to the woman.
Despite not finding the DHB in breach of the Code, the Commissioner also made recommendations for improvement for the
DHB including using this report as a basis for staff training.
The full report on case 19HDC01517 is available on the HDC website.