A woman who repeatedly sought help for severe stomach pain and dramatic weight loss, told her GP she felt “fobbed off” as she was never referred for specialist care – despite clear red flags that later led to a diagnosis of terminal bowel cancer.
The woman, referred to as Ms A, died at age 43, around 18 months after a diagnosis of metastatic colonic adenocarcinoma.
Her symptoms, including severe abdominal pain, bloating, vomiting, and dramatic weight loss, were repeatedly attributed to irritable bowel syndrome (IBS) by doctors at her local GP centre over a two-year period.
According to a Health and Disability Commissioner report released today, Deputy Commissioner Dr Vanessa Caldwell found that one of Ms A’s doctors, referred to as Dr E, breached the Code of Health and Disability Services Consumers’ Rights by failing to provide care with reasonable skill and attention.
“There were three separate missed opportunities for a referral and potential diagnosis between December 2021 and March 2022,” Caldwell wrote.
Despite Ms A’s worsening symptoms, Dr E did not examine her or document her weight during a key appointment in December 2021. She was barely able to eat, had lost significant weight, and was tearful during the consultation.
“Feels she has been fobbed off and wants some answers,” Dr E documented in his notes.
He ordered blood and stool tests and an abdominal ultrasound but did not refer her to gastroenterology – even though her weight loss was considered a clinical red flag.
“It would be common practice to have referred Ms A urgently to gastroenterology for a review and a colonoscopy,” said HDC clinical adviser Dr Fiona Whitworth. “Even if the results of the ultrasound and bloods were normal.”
Dr E later told the commissioner he believed Ms A’s weight loss could be due to her restrictive diet and difficulty keeping food down. He said her symptoms were longstanding, her test results were reassuring, and she was responding to medication.
Whitworth was also critical of Dr E’s failure to follow up in person after receiving Ms A’s test results in January 2022 and, again, after a phone consultation in March.
“With a significant weight loss, it would have been good clinical practice to initiate a referral… with a high suspicion of cancer priority,” Whitworth said.
Ms A was eventually diagnosed with bowel cancer in May 2023, after raising her symptoms with an ENT registrar during a hospital follow-up for a previous melanoma. A biopsy of a neck node revealed metastatic cancer, and further investigation confirmed colonic adenocarcinoma.
ACC later accepted a treatment injury claim, stating the delay resulted in the cancer progressing from Stage 3B to Stage 4.
While Dr E has since moved overseas, he accepted the HDC’s findings and had completed further education on colorectal cancer and early diagnosis in young adults. He was asked to provide a written apology to Ms A’s family.
The GP centre itself was not found in breach, and other doctors involved received educational comments. The report would be sent to the Medical Council and published on the HDC website for educational purposes.
