Health and Disability Commissioner Anthony Hill has released a report finding the bay of Plenty District Health Board in breach of the Code of Health and Disability Services Consumers' Rights for failing in the care provided to a man receiving surveillance and screening at the DHB.

A man was receiving hepatoma ultrasounds and three yearly surveillance endoscopies at the DHB.

The doctor at the DHB decided that a repeat hepatoma ultrasound was required and intended to order this when the man attended his next surveillance endoscopy in six months' time.

Before the man could attend the surveillance endoscopy at which his repeat hepatoma ultrasound was to be ordered, all surveillance endoscopies were suspended by the DHB due to resource constraints. This resulted in the hepatoma ultrasound not being ordered.

The DHB notified the man's GP and placed notification on its website of this suspension. A staff member from the GP's clinic telephoned the man to inform him that the DHB had suspended surveillance endoscopies and he was offered the choice to undertake a private surveillance endoscopy, which the man refused as he was not symptomatic.

The man consulted another GP who arranged an appointment at the DHB. He was referred for a scan which identified a 7.5cm tumour in his liver.

This tumour may have been picked up by a hepatoma ultrasound, however this was not carried out due to the suspension of surveillance endoscopies. The man was referred for palliative care.

Anthony considers the DHB was responsible for the operation of the clinical services it provides, and are responsible for service failures.

'The DHB had an organisational duty to facilitate continuity of care and is responsible for ensuring it has robust systems in place to provide an appropriate level of care.”

He has made a number of recommendations to the DHB in relation to processes for monitoring patient surveillance including developing a standardised protocol for follow up arrangements for all patients with cirrhotic liver disease, conducting a review of the effectiveness of the protocol and considering the implementation of a database for patients on dual surveillance programmes.

The DHB apologised to the man.