HDC findings from investigation into woman’s death from lung cancer anger widower

A former Karamea man is furious at the outcome of an investigation by the Deputy Commissioner for Health and Disability into his wife’s death from lung cancer.

Kent Vickerman said the commissioner’s report provided no accountability for his wife Nijole’s misdiagnosis.

“My wife died, she never had to… it’s heartbreaking… (The report) is just a big cover-up.”

Nijole, a fit and active horticulturist, runner and non-smoker, was diagnosed with terminal lung cancer by the West Coast District Health Board (now Health NZ West Coast) in March 2020. She had been ill for more than 10 months, he had had dozens of tests and doctor appointments, and has been treated for sinus disease.

He died on December 22, 2022, aged 64.

Deputy Health and Disability Commissioner Carolyn Cooper concluded that Health West Coast did not breach the Health and Disability Services Consumers’ Rights Code.

But she was concerned that Karamea Health Center staff had not considered an x-ray and an alternative diagnosis sooner, given that Nijole’s symptoms had not fully resolved.

Cooper was also concerned that Nijole’s pattern of presentations had not been considered in each consultation. He reminded Heath West Coast of the importance of overall coordination and clinical supervision in patient care.

However, Cooper found that most of the care provided to Nijole was appropriate, especially considering mitigating factors. These did not include “red flag” symptoms and a CT scan of the sinuses appeared to support the diagnosis of sinusitis.

Health West Coast told him its primary care clinical staff had been informed about the risks of dual diagnosis and confirmation bias. The clinical teams had discussed the limitations of the HealthPathways tool.

Health West Coast also said it continues to work to improve staffing and strengthen its team care to provide greater continuity of patient care.

Kent said his wife should have received a chest x-ray within two months of her first presentation at Karamea Health Centre.

He described the deputy commissioner’s investigation as “appalling” and said it was too narrow in scope.

Cooper looked at whether the West Coast District Health Board (now Health NZ West Coast) had provided appropriate care to Nijole between April 2019 and March 2020, inclusive.

Cooper’s report said Nijole had presented at Karamea Health Center 15 times between April 23, 2019 and March 6, 2020 with an ongoing cough, skin lesions, recurring sinus problems and a persistent postnasal drip. She was seen by seven different doctors, four of whom were GPs. Her symptoms were treated as sinusitis, according to the report.

“I am concerned that overall responsibility for Ms. Vickerman’s care does not appear to have been ‘owned’ by any particular doctor. It is also unclear whether any of the seven different doctors analyzed Ms. Vickerman’s pattern of presentations in its entirety. ..

“I am concerned that Ms. Vickerman’s care lacked overall coordination and clinical oversight.”

Nijole’s own notes over time say that the various medications he was prescribed made little difference. She felt cheated and frustrated.

In February 2020, after Kent demanded that his wife have a chest X-ray, a family doctor ordered one to be done in four weeks.

In March 2020, after a chest X-ray and CT scan, Vickerman was diagnosed with stage four lung cancer.

Nijole wrote in his notes: “It had taken 10 (months) of chronic cough, extreme fatigue (sic) and many other ailments to finally get a result.”

Kent disputed much of the information doctors provided to the deputy commissioner, particularly that Nijole was not continually complaining of a cough and that her symptoms were improving, according to Cooper’s report.

He said Nijole had “continually complained about his cough” which “only got worse” and he was repeatedly given medication which did not help. He worried that doctors would spend 10 months trying to diagnose a sinus problem.

He said that if his wife’s cancer had been caught early, instead of her being constantly prescribed antibiotics, her type of cancer would have a 90 percent recovery rate.

Health West Coast accepted that a chest x-ray could have been carried out earlier and that this would likely have led to an earlier diagnosis, the report said.

But Health West Coast said there were no “red flags” of serious lung illnesses, such as a productive cough, coughing up blood, shortness of breath, chest pains, weight loss or fever.

“Unfortunately, Ms Vickerman had two different conditions presenting with the same constellation of symptoms at the same time,” Health West Coast said.

ACC accepted a treatment injury claim from Nijole in January 2021. It agreed to pay around 90 per cent of his usual earnings on a weekly basis, as well as a lump sum and ongoing medical, care and travel costs.

The support was retroactive to September 19, 2019, when ACC said a chest x-ray should have been taken and a diagnosis made.

Cooper’s Recommended West Coast Health:

(L.B.

• Provide evidence, within three months of your report, that Karamea Health Center doctors had reviewed the HealthPathways Diagnostic Error; learning resource for clinicians and any lessons recorded by staff after review;
• Provide an update, within three months, on any changes made as a result of the complaint and provide evidence that an anonymous case study has been used as a learning opportunity for staff.

Westport News has sought comment from Health West Coast.

In a cover letter to Kent, Cooper praised him for his continued efforts to defend his wife and for seeking a resolution to the complaint.

But he said his concerns about his wife’s care after her diagnosis on March 12, 2020 were outside the scope of his investigation.

Kent remarried and now lives in Thailand.

– Westport News