A woman at high-risk of liver cancer has died of the disease after slipping through a crack in the health system.

Deputy health and disability commissioner Vanessa Caldwell found there was a significant delay in the woman's diagnosis after her regular check-ups stopped in 2019.

Having a liver disease meant she was known to be at high-risk for the cancer, and had undergone surveillance ultrasounds since 2017.

The woman was only diagnosed after presenting to an emergency department with nausea and upper back pain in 2022. She died after receiving palliative care.

Dr Caldwell found failures with the continuation of the woman's care, after Health New Zealand - Te Whatu Ora made changes to the radiology referral systems without appropriate safety-nets.

"I am particularly concerned that when it was determined that surveillance ultrasound scans would require a new referral, there appears to have been no consideration as to how this might pose a risk to patients requiring new referrals for repeat scans to be generated, and no thought to develop a plan as to how to mitigate this."

However, she says it's not the woman's gastroenterologist's sole responsibility to make new referrals for patients under surveillance, and that a better system (with safety-nets such as a message to general practitioners about the change) should have been in place.

A processing error meant the woman's six-monthly follow-up outpatient appointments with the gastroenterologist were also not booked, which Caldwell said was a missed opportunity to identify that the woman was overdue for her surveillance scan.

The Health New Zealand district involved had completed an adverse event review and Caldwell recommended it provide evidence those recommendations had been implemented. She notes representatives of the agency had met with the woman before her death to apologise for the delays.

"Whilst ultimately earlier detection may not have resulted in a different outcome for [the woman], it would likely have allowed her time to accept the diagnosis and spend more time as she would have wanted," the deputy commissioner's report reads.

Caldwell also advises the district to set out a process ensuring when new systems were implemented, appropriate safety-nets were in place.

-RNZ.