Woman suffers horrific burns during surgery

A West Coast mother admitted to Grey Base Hospital for day surgery suffered horrific burns during the procedure and has been left with a significant permanent disability.

Jo Partridge spent seven weeks in the burns unit of Christchurch Hospital following her ordeal. Eleven months on and she is still unable to put her children on her lap, due to pressure on her pelvis.

She has been to theatre more than 35 times, and is unable to live a normal life.

The West Coast District Health Board has apologised for a "catastrophic equipment failure" but maintains its hospital staff are "competent and capable".

The Health and Disability Commissioner is investigating the case, which was reported briefly last year by the West Coast District Health Board as a 'serious and sentinel event'.

In May 2012, Mrs Partridge underwent a thermal ablation - a internal gynecological procedure - but four minutes into the procedure the intrauterine balloon containing saline heated to 86degC and burst inside her.

The hot liquid spilled under pressure into her vagina, and over her genitals and buttocks. It came out with enough force to splash the surgeon in the face.

Mrs Partridge says she was left for five days with no internal treatment.

The DHB's own root cause analysis report says "immediate cooling measures were not undertaken".

At the end of the procedure, staff noted evidence of burns and scalding. It was subsequently discovered that she had "severe burns to her vagina and perineum".

Theatre staff had "underestimated" how much of the heated saline had spilled.

A hospital report said the surgical method had been used on the West Coast since 2004 without incident. The staff were properly trained, and testing of the machine found no faults. However, the report also recommended the thermal ablation system be permanently removed from the hospital.

Mrs Partridge and her husband Scott took legal advice before going public, and are limited in what they can say.

But they have one clear message: "Staff should be stood down while the Health and Disability Commissioner is investigating."

Mr Partridge has lost his job due to having to take time off work to look after their young children and his wife, who is suffering from chronic pain.

"With common sense and basic first aid, life would be so much different now," Mrs Partridge told the Greymouth Star.

West Coast DHB chief executive David Meates said the incident was the result of "catastrophic equipment failure".

The procedure was no longer used at Grey Base Hospital, and the board had apologised to Mrs Partridge.

The incident was reported to Medsafe and the Health Quality and Safety Commission, he said.

Asked if there had been any delay in treating her burns, he said third-degree burns did not present themselves immediately.

The case would be thoroughly investigated by the Health and Disability Commissioner.

Mr Meates said the hospital had not been able to ascertain why the balloon failed in the first place.

"It was not something people thought possible to occur."

The liquid should have been extracted by the machine.

He said the DHB would comply with any recommendations and lessons from the Health and Disability Commissioner, saying it was important after any serious event that the board did not bury its head in the sand.

An improved procedure for the management of burns had since been implemented at Greymouth.

Asked about standing staff down during the inquiry, Mr Meates reiterated that it was a catastrophic equipment failure and he did not want to make a knee-jerk reaction. Hospital staff were "competent and capable".

The doctor who treated Mrs Partridge had provided "excellent service" and this was the first serious incident involving that doctor.

Grey Base still does thermal ablations, but not the balloon method.

By Laura Mills of the Greymouth Star

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