The Health and Disability Commissioner Morag McDowell has found that the senior doctor overseeing the procedure and the obstetrics and gynaecology trainee who performed the procedure breached the Code of Health and Disability Services Consumers’ Rights for failing to provide services with reasonable care and skill.
The loop electrical excision procedure (LLETZ) to remove the abnormal cells began without local anaesthetic, causing the woman significant pain, McDowell said in a report released today.
The woman has been receiving counselling and support from her GP for post-traumatic stress disorder as a result of what happened to her.
McDowell said administering local anaesthetics was a basic step in the procedure and that most clinicians would have done this before starting.
"The standard of care applicable is the care and skill that an ordinarily careful peer of the clinicians involved would exercise under similar circumstances," McDowell said.
A LLETZ procedure usually takes only five to 10 minutes.
The woman said in her complaint that as the procedure was about to begin, the doctor told her: "Now you’re going to hear a buzz from the machine but you won’t feel a thing."
But she was then "filled with the most incredibly horrific pain" and was screaming as she felt the electrically surging wire "cut through her cervix".
Dr B, the trainee, told HDC that once the initial vaginoscopy had been performed, she began the LLETZ procedure by performing a "touch test" to ensure the electrical current was working.
She said that this test caused the woman a significant amount of pain, causing her to yell out, and it was then realised that an anaesthetic had not been administered before the test.
The woman, who is not named in the decision, said she was then told by one of the staff that they "had to get through that loop before they could address the pain", and that she was scolded for shaking and was held down in an attempt to keep her still.
Dr B told HDC that she did not remember any staff holding the woman down or scolding her for moving.
She said the LLETZ loop was removed immediately without reactivation, and all staff apologised to the woman.
She then swapped places with the senior doctor, Dr A, who called for and administered the local anaesthetic.
The woman said at no time did anyone apologise, and she also claimed to have experienced a burning sensation in her vagina and on her upper thighs from the iodine given as part of the procedure but the clinicians did not respond to her concerns.
Dr B noted that iodine was not applied to a patient’s thighs and stated that had they been aware of a burning sensation, the clinicians would have tried to relieve this with saline solution and offering pain relief.
The woman was then asked whether she would like to reschedule the procedure so that it could be completed under general anaesthetic, or if she wanted to continue with the procedure.
The woman said she was experiencing "immense shock and pain" but she agreed to continue through fear that the cells would develop into cancer if left untreated.
Dr B told the HDC during the inquiry that there was no local anaesthetic syringe on the procedure tray which resulted in a delay of "not more than five minutes" as the syringe was prepared and the local anaesthetic was administered.
The senior supervising doctor, Dr A, told HDC that when overseeing a trainee performing a LLETZ, she usually stood behind and watched all steps.
She did not notice that the local anaesthetic solution had not been injected into the cervix, which was why she did not intervene.
She acknowledged that this was an error of judgment on her part and a significant omission and a breach of standards.
In response to the patient’s concern about iodine burning, Dr A said more could have been done to advise her of the increased risk of symptoms from the application of iodine during the preliminary vaginoscopy and that it was possible the woman may have developed a late reaction to it, which would not have been picked up during her time in the clinic.
Dr A told HDC that the woman did not present for a follow-up appointment and would not speak to her over the phone when she called to follow up.
She then wrote a letter to the woman and copied in her GP to apologise, and to discuss options for future care.
Te Whatu Ora - Health NZ said if its team had persisted in following up with the woman a six-month period would not have elapsed before she received a formal apology and, importantly, the opportunity to offer her support to deal with the trauma would not have been missed.
Health NZ described it as a "significant learning" for the staff involved and for women’s health services in proper follow-up with patients following adverse events.
McDowell was satisfied that the issues outlined were primarily the responsibility of the individual clinicians involved but she was critical over Health New Zealand - Te Whatu Ora Te Toka Tumai Auckland’s failure to upload the woman’s consent form to her file.
She also said a more empathetic approach was warranted by Health New Zealand after the adverse event, including personal contact to assist in the woman’s recovery.
She also recommended that the gynaecologist and the registrar formally apologise to the woman and that Health New Zealand consider implementing the use of saline wash at the end of all gynaecological procedures that use iodine, and consider updating its adverse event policy to require a follow-up for patients who have suffered an adverse event.
Health New Zealand, the gynaecologist and registrar have since made changes to their practice.
- Tracy Neal, Open Justice reporter
