Doctors at Auckland's North Shore Hospital failed to order the tests needed to diagnose bone cancer in a patient with a history of cancer.
That's the conclusion of Health and Disability Commissioner Anthony Hill, who says in a report released on Monday that opportunities were missed when questions should have been asked.
Mr Hill says the unnamed woman had had a mastectomy for invasive breast cancer in 2002, with a high chance of recurrence.
But when she was admitted to hospital five years later with sudden, severe back pain, doctors put it down to muscle spasms and did not order an MRI or bone scan. The woman said her request for one was rudely refused.
Seven months later, an MRI scan obtained by her GP revealed bone cancer in her spine and pelvis. She died last year.
Mr Hill says the woman had complex underlying disorders but doctors employed by the Waitemata District Health Board failed to take the steps needed and to communicate with other medical experts.
He says the doctors made assumptions, including that the hospital's cancer experts would check for cancer later.
The woman's husband wrote to Mr Hill in 2008 claiming the doctors had tunnel vision and Mr Hill says that's correct.
Board accepts findings
The DHB's chief medical officer, Andrew Brant, says the board accepts the findings.
"We have learnt from this case," he says, "and what I expect is that our clinicians are communicating and talking to each other within the services to make sure that we are constantly thinking about what is the clinical problem in front of us."
Dr Brant says electronic health records being introduced in Auckland will help reduce the risk of anything similar happening in future.