A woman died of ovarian cancer after multiple doctors and investigations failed to diagnose her for five years.

A report published on Monday has found the Northland District Health Board - now Health New Zealand - Te Whatu Ora Te Tai Tokerau - missed multiple opportunities to diagnose and treat the woman, who was in her fifties, Deputy Health and Disability Commissioner Dr Vanessa Caldwell said.

Between 2014 and 2019, the woman had multiple referrals and many investigations over post-menopausal bleeding, but no treatment plan was put in place, and surgery was not offered.

When a MRI scan was finally done, it confirmed the woman had stage four ovarian cancer, and she died only a few months later.

"I am critical of the failure by multiple clinicians to consider the causes of the woman's symptoms critically, manage the post-menopausal bleeding appropriately, and undertake necessary imaging in the form of pelvic ultrasounds and/or CT scans," said Caldwell.

She said the woman's condition warranted a hysterectomy or hormonal therapy, but it was not offered, nor was imaging undertaken, which could have confirmed an earlier diagnosis.

"The missed opportunities to provide treatment information are attributable to multiple clinicians, and signify a failure at an organisational level, for which Health New Zealand is responsible," Caldwell said.

The matter continued to cause the woman's whānau "significant distress", she said.

The Commission found the failure breached the woman's right to receive services of an appropriate standard, and her right to be provided with treatment options, as guaranteed under the Code of Health and Disability Services Consumer's Rights.

"In my view, offering support only at the start and end of care is not a culturally responsive or appropriate approach, especially given the woman's long-standing engagement with the healthcare system," she said.

Health New Zealand has made a number of changes since the woman's death, and further recommendations have been made by Dr Caldwell in the report.

The recommendations include a written apology to the woman's whānau, developing a policy for unresolved post-menopausal bleeding, and an audit of patients who have re-presented to Te Whatu Ora Te Tai Tokerau over the past 12 months with symptoms of unresolved post-menopausal bleeding.

The report also recommended Te Whatu Ora Te Tai Tokerau to consider developing or reviewing systems that identified and addressed the need for ongoing cultural support.

This story was originally published by RNZ