The former Southern District Health Board breached its consumer code with delays to non-surgical cancer services, the Health and Disability Commissioner has found.
The commissioner, Morag McDowell, has made a number of recommendations to Te Whatu Ora and Te Aho o Te Kahu, the Cancer Control Agency, around preventing further breaches.
McDowell's investigation was launched after concerns about the delays in first specialist assessments for medical oncology, radiation oncology, and haematology services.
In 2021, Melissa Vining contacted the commissioner after her husband Blair was diagnosed with cancer and was told he had 6-8 weeks to live but that the wait time to see an oncologist was 12 weeks.
"Te Whatu Ora Southern failed to recognise and respond to the clinical risk associated with lack of capacity within Southern Blood and Cancer Services and, as a result, cancer patients were harmed," the Commissioner found.
"This was due to poor overall clinical governance systems, including inadequacies in quality measures and indicators, and poor relationships between clinicians and executive leadership."
On-time treatment is crucial, McDowell said, "for reducing morbidity and mortality for cancer patients and delays also have a significant psychological impact on patients and their family/whānau".
She added: "Providers owe a duty of care to people waiting for resource constrained specialist procedures, particularly when the intervention is time-critical."
Recommendations made to the organisation following the commissioner's investigation include establishing a single point of contact for patients on the waiting list and reporting on progress made after two previous external reviews.
Te Whatu Ora Southern continues to face significant specialist workforce shortages, McDowell acknowledged, which hampers the district's ability to provide some services.
McDowell recommended Te Whatu Ora national office update the Commission on what's being done to address geographic disparities in access to timely cancer services.
Te Aho o Te Kahu was also asked to provide an update on its progress on working with Te Whatu Ora Southern to address the delays.
Patients are guaranteed the minimisation of harm and an optimised quality of life by the Code of Health and Disability Service Consumers' Rights.
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