19 July 2024

Woman given unnecessary colonoscopy due to NHI number mix-up

A mix-up of National Health Index (NHI) numbers by a specialist resulted in a woman having to undergo an unnecessary colonoscopy just two days after her previous colonoscopy procedure.

An investigation by the Health and Disability Commission has found the woman patient received a colonoscopy she did not require as her earlier results were reported as normal.

Based upon the results of a surveillance colonoscopy provided by Te Whatu Ora , it was recommended that five-yearly surveillance colonoscopies continue.

According to HDC, despite these results, the woman received a telephone call from the colonoscopy clinic two days later advising that the reporting specialist had referred her for a further scheduled urgent colonoscopy.

The woman left voicemails for the referring specialist to confirm the reasons for the further procedure, but did not receive any response.

At the colonoscopy appointment, the woman asked the registered nurse undertaking the consenting process why the colonoscopy was required. The nurse provided no reasoning for the colonoscopy and did not record the query in the patient’s clinical records or follow up with the specialist who was to undertake the colonoscopy.

During the procedure, the specialist undertaking the colonoscopy (who was not the referring specialist) noted that the findings on the referral form were not consistent with what was being seen in the colonoscopy in real time.

The specialist performing the procedure contacted the referring specialist and it was picked up that there had been an accidental mix-up of National Health Index (NHI) numbers, and the incorrect patient was having the urgent colonoscopy.

After the woman’s sedation had worn off, the specialist informed her of the mix-up in her having an unnecessary colonoscopy.

The Deputy Health and Disability Commissioner, Vanessa Caldwell, considered this as a “serious incident” and that Te Whatu Ora failed to provide services to the woman with reasonable care and skill. As such, Caldwell found Te Whatu Ora in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights.

The woman has already received a verbal apology from the referring specialist and from the hospital’s Clinical Quality and Risk Manager.

Te Whatu Ora confirmed and provided evidence that it has complied with these recommendations. The Deputy Commissioner Caldwell was satisfied that the recommendations were an appropriate response to the incident and will mitigate a similar incident occurring.

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