In a 16-page decision released yesterday, Aged Care Commissioner Carolyn Cooper said the lack of appropriate protocols from Health New Zealand Te Whatu Ora Southern (HNZ Southern) "strongly contributed to the dangerous situation" where a surgeon requiring supervision did not seek advice from colleagues at another hospital.
Instead, the inexperienced surgeon asked for and was given approval for another doctor — who was not employed by HNZ Southern — to help with the surgery, in which a procedure the patient did not consent to was performed.
The events in question unfolded in 2019 at a public hospital managed by HNZ Southern.
A 77-year-old man — known as "Mr A" — presented to the hospital after suffering a heart attack and developed headaches and vision problems in the following days.
A benign tumour in the pituitary gland was found to be bleeding and was putting pressure on a region at the base of the brain where the optic nerves intersected.
This was managed with medication changes until the neurosurgery team — led by "Dr B" — believed Mr A’s vision had deteriorated acutely and urgent surgery was required.
Dr B "recognised that he did not have adequate experience to undertake this procedure", and permission was granted for "Dr C" to assist with the surgery.
"Dr C was not an employee of Health NZ Southern and was not credentialled to operate at [the hospital]", Ms Cooper said.
"At the time of the events, he had not performed surgery for one year and had not completed a pituitary tumour resection for two and a-half years."
Dr B’s on-site supervisor was on annual leave at the time, and it was expected he would seek advice from an available supervisor in cases outside his scope of expertise.
But he did not seek advice from another supervisor nor an on-call neurosurgery consultant, both based at a different hospital, Ms Cooper said.
During the surgery, it was decided to extend the procedure to access further tumour tissue.
Dr C took over as the principal surgeon and "extensive bleeding" occurred.
As a result of damage to the carotid artery, Mr A suffered a cardiac arrest and significant blood loss before the bleeding was able to be controlled.
An adverse event report was completed by HNZ Southern and concluded the root cause of the event was a failure by Dr B to contact his colleagues at the other hospital to obtain advice.
According to the report, other contributing factors included an insufficient plan in place to manage a patient who required complex surgery.
"This resulted in an inexperienced surgeon performing urgent surgery alongside another surgeon who was not employed by Health NZ Southern.
"This led to the decision to attempt further tumour removal, which caused bleeding, cardiac arrest and death."
This decision was a key event during the surgery, Ms Cooper said.
"If the decision to extend the procedure had not been made, surgery would not have continued following the initial evacuation, and the damage to the carotid artery would not have occurred."
It was evident several aspects of the care provided to Mr A did not meet accepted standards.
Ms Cooper found that Dr B, Dr C and HNZ Southern all breached the patient’s right to have services provided with reasonable care and skill.
The "impromptu involvement" of a non-HNZ Southern employee to support a surgeon lacking experience in the procedure was "an unusual situation".
It was also "more likely than not" that Mr A was not adequately informed of Dr C’s participation and role in the operation.
There was no record in the operation consent form nor preoperative discussion notes that the procedure could be extended.
"In making the decision to extend the operation, Mr A received a procedure to which he did not consent."
It was concerning that HNZ Southern did not have adequate plans or protocols in place to supervise and support staff in Mr A’s case, Ms Cooper said.
HNZ Southern chief medical officer Dr David Gow said it accepted the findings regarding Mr A’s care in 2019.
"We are sincerely sorry for the patient’s experience and acknowledge that our failures have caused significant distress for the patient’s whānau.
"We have sent a written apology to the patient’s whānau, and we are open to directly engaging with them to discuss our own internal findings into this incident."
The South Island’s regional approach to neurosurgery services continued to develop, Dr Gow said.
Since 2019, changes to practice and procedures had been made in an ongoing effort to provide better care to all patients.
"We accept all the commissioner’s recommendations and are working to implement them."
