The Health and Disability Commissioner has censured a family doctor who failed to adequately refer his patient to hospital after symptoms suggesting his cancer was back.
The 62-year-old patient was treated for cancer of the oesophagus.
Six months later, the man's condition worsened. He asked his GP for a scan.
The GP sent the request without disclosing the man's symptoms. The hospital lost the referral letter.
A month later, he returned with new symptoms. Again, the GP sent a referral without any indication of them.
When the man did receive a scan, it showed the cancer was back.
A laparoscopy was scheduled, but the cancer meant the surgeon could not complete the procedure.
The man never regained consciousness.