A patient with a history of cancer was admitted to the DHB's Medical Service with back pain. While the Medical Service was aware that the woman was with the Oncology Service, it did not discuss the woman's admission with Oncology. After several months of pain management the woman had a bone scan which indicated metastatic bone disease in her back.

In responding to the Commissioner's investigation, the DHB noted that the Oncology Service had full access to the woman's medical records, and that the Medical Service could expect the issue of metastasis to be considered by others. However, the Commissioner did not accept "that it was reasonable to assume that the possibility of cancer would be picked up by the Oncology Clinic without directly informing that clinic about [the woman's] admission". The Commissioner also found that given the patient's history and her presentation on admission, an MRI scan or bone scan should have been done to exclude the possibility of metastatic bone disease,

The Commissioner concluded that "this was a case of different services....each considering a patient from their own specialist viewpoint without having regard to the bigger picture". The DHB was found in breach of Right 4(1) of the Code for the Medical Service's failure to adequately investigate the cause of the back pain, and in breach of Right 4(5) for the failure of the Medical Service to communicate adequately with the Oncology Service. 10HDC00703