Delay In The Diagnosis Of Multiple Sclerosis In Woman

Deputy Health and Disability Commissioner Dr Vanessa Caldwell has found Te Whatu Ora - Waitaha Canterbury (WC), formerly Canterbury District Health Board, and a GP in breach of the Code of Health and Disability Services Consumers’ Rights (the Code). In her decision, Dr Caldwell found that service delivery failures, and failures to provide a woman with care of a reasonable standard, resulted in a delayed diagnosis of multiple sclerosis (MS).

A woman was referred by her GP in 2010 to the ophthalmology service at the public hospital with sudden and unexplained vision loss. She was diagnosed with demyelinating optic neuritis (inflammation of the optic nerve, often associated with MS). An MRI confirmed the optic neuritis and also noted several areas of abnormal white matter lesions in the brain, raising the possibility of primary demyelination. In 2011, the woman was referred to the neurology service for further assessment, and was prioritised as ‘semi-urgent,’ but due to limitations on resources, the referral was declined and the woman was not seen by the neurology service. The woman was advised to remain under the care of her GP.

The woman presented to a GP at a new medical centre in 2015 due to tingling in her left arm and leg, which had caused her to fall over on a number of occasions. The GP ordered screening tests to investigate a provisional diagnosis of a mini-stroke or an inflammatory disorder, but did not refer her for specialist assessment by a neurologist, or put in place a management plan for follow-up advice or structured review of the test results.

The woman presented to the medical centre again in 2018 and was seen by a different GP, whose impression was that she had a migraine and inner-ear disorder causing vertigo. A few days later, the woman called the medical centre due to ongoing symptoms, but the clinical records do not indicate whether the nurse who took the call discussed this with the GP, or what actions were taken to follow-up with the woman.

In 2019, the woman was referred urgently to the neurology service by the medical centre after presenting to another GP, who found clinical documentation from 2011 noting that the woman’s MRI had shown features consistent with demyelination. The woman was diagnosed with MS a couple of weeks later.

Dr Caldwell acknowledged "the distress suffered by the woman as a result of the services she received from Waitaha Canterbury".

"The possibility of MS had been raised in 2010, but the diagnosis was confirmed only nine years later. This delayed diagnosis resulted in missed opportunities for the woman to obtain earlier treatment for her condition.

"I acknowledge the extraordinary circumstances that faced Waitaha Canterbury following the earthquake in 2011 and the resulting resource constraints, but I do not consider it was reasonable for the woman’s neurology referral to have been declined without any further advice being offered.

"I consider the service failure was a contributing factor to the delay in the woman receiving the neurological review and treatment she required," says Dr Caldwell.

Dr Caldwell also found a breach of the Code by the GP who saw the woman in 2015.

"The care provided by the GP did not meet the required standard due to the lack of a referral for specialist assessment by a neurologist, and the lack of a follow-up action plan," says Dr Caldwell.

While Dr Caldwell did not find the medical centre in breach of the Code, she made adverse comment about the nurse’s lack of documentation about telephone discussions and follow-up actions with the woman.

Following the events of this case, WC made multiple changes to its processes, systems and procedures. While WC currently does not have a specific neurology referral pathway, it follows the Ministry of Health derived policy or guidelines for triage. WC’s neurology service has activated an e-triage system, and immediate management advice and strategies are offered to the referrer for possible implementation prior to the neurology clinic appointment. It is now normal process for departments to respond to both internal and external referrals and WC has employed a full-time clinical nurse specialist and a half-time registered nurse specifically for MS outpatient work.

Taking into consideration the changes made by WC, Dr Caldwell recommended that WC provide a formal written apology to the woman for the deficiencies in care identified, and use the report as a basis for staff learning. The GP has retired from practice, but Dr Caldwell recommended he provide a formal written apology to the woman. She further recommended the nurse undertake training on documentation.

Editors notes

The full report of this case will be available on HDC’s website. 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 and HDC’s naming policy 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).

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