The woman visited multiple GPs on 25 separate occasions in a single year seeking treatment, yet was not diagnosed until she was overseas.

On Monday, a report released by New Zealand’s Deputy Health and Disability Commissioner Deborah James found one GP in breach of the Code of Health and Disability Services Consumers’ Rights for failures in its care of the woman, referred to as Mrs A.

In 2016, Mrs A, who was in her 20s, first visited the medical centre where she was treated for anaemia.

Mrs A visited the centre a further three times between 2016 and 2017, continuing to suffer from low iron.

In 2018, Mrs A returned to the medical centre.

This was the first of 22 appointments, where she would be seen by multiple doctors, and nurses.

Throughout 2018, she continued to receive iron injections, however, no further efforts were made to investigate the cause of the anaemia.

Fifteen months after she first went to the medical centre, Mrs A presented to A&E complaining of back and abdominal pain.

A few months later, Mrs A returned to A&E via an ambulance with abdominal pain, vomiting, and diarrhoea.

She visited A&E for a third and final time with flu-like illness and haemorrhoids – at the time she described her pain as being “severe”.

Throughout the year Mrs A would continue to be seen by two doctors, Dr C and Dr D, at the medical centre for symptoms including persistent anaemia, abdominal and pelvic pain, and diarrhoea.

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On her final visit, Dr C referred her for a non-urgent ultrasound to investigate her chronic abdominal pain.

The ultrasound was booked outside of the four-week timeframe requested.

But, while overseas in 2018, Mrs A was admitted to a hospital with sudden abdominal pain, and diagnosed with stage four terminal cancer.

Due to the inoperable and advanced nature of Mrs A’s cancer, she was discharged into hospice care, where she died a few weeks later.

James acknowledged “the complexity and chronicity of the woman’s medical conditions” made it a “difficult background upon which to provide care and diagnosis”.

But she was critical Dr C did not investigate the cause of Mrs A’s persistent and unexplained anaemia more thoroughly and said opportunities to diagnose the cancer several months earlier had been missed.

She was also critical Dr D had not brought the results of the blood test to the attention of the first GP.

However, as the majority of the care provided by Dr D was appropriate she was not found in breach of the Code.

“I consider the deficiencies in the first doctor’s care were individual failures, and I am also critical of the lack of clarity as to which GP had the primary responsibility for the woman’s care.”

James noted the need for providers to use critical thinking to reassess possible diagnoses when patients repeatedly presented with persistent and significant symptoms that failed to respond to treatment.

She recommended both GPs provide written apologies to the woman’s whānau, or extended family.

She also recommended both GPs review the health pathways guidance on iron deficiency and undertake an audit of patients treated in the last 12 months.