In a 16-page decision by the Health and Disability Commissioner, made public today, Carolyn Cooper said the lack of appropriate protocols from Health NZ 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 Health NZ Southern - to help with the surgery, which involved a procedure the patient did not consent to.
The events in question occurred in 2019 at a public hospital managed by Health NZ Southern.
The 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 intersect.
This was managed with medication until the neurosurgery team - led by a man known as ‘‘Dr B’’ - believed Mr A’s vision had deteriorated acutely and urgent surgery was required.
Dr B recognised he did not have adequate experience to undertake the procedure, and permission was granted for a ‘‘Dr C’’ to assist with the surgery.
‘‘Dr C was not an employee of Health NZ Southern and was not credentialed 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 away on annual leave, but it was expected he would seek advice from an available supervisor in cases outside his scope of expertise.
He did not seek the advice from another supervisor nor an on-call neurosurgery consultant, both based at a different hospital, Ms Cooper said.
‘‘According to Dr B, [the on-site supervisor] and Health NZ Southern were aware that his usual practice was to make independent clinical decisions without discussion with a supervisor, and this was not questioned.’’
According to Dr B and Dr C, Mr A was informed of the latter’s involvement during a preoperative discussion with Dr B.
But this discussion was not documented and Dr C confirmed he did not speak to Mr A before the operation, Ms Cooper said.
‘‘It appears that Dr C’s participation in the surgery is not recorded in any of the consenting documentation or the handwritten surgical note.’’
During the surgery, it was decided to extend the procedure and ‘‘extensive bleeding’’ occurred.
Mr A suffered a cardiac arrest and significant blood loss before the bleeding was able to be controlled.
‘‘Subsequent testing showed that Mr A had suffered widespread loss of function on both sides of the brain due to a lack of blood flow.
‘‘Sadly, Mr A passed away.’’
An adverse event report was completed by Health NZ 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.
Other contributing factors included an insufficient plan in place to manage a patient who required complex surgery, Ms Cooper said.
‘‘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.’’
Ms Cooper said it was evident several aspects of the care provided to Mr A did not meet accepted standards, and considered Dr B to have breached multiple parts of the Code of Health and Disability Services Consumers’ Rights.
The impromptu involvement of a non-Health NZ Southern employee to support a surgeon already lacking experience in the procedure was ‘‘an unusual situation’’ and the absence of documentation was concerning, she said.
It was ‘‘more likely than not’’ that Mr A was not adequately informed of Dr C’s participation and role in the operation.
It was also not recorded in the operation consent form nor appropriate discussion notes that the procedure could be extended - nor the possibility of the risk of ‘‘severe bleeding’’.
‘‘In making the decision to extend the operation, Mr A received a procedure to which he did not consent.’’
It was concerning that Health NZ Southern did not have adequate plans or protocols in place to supervise and support staff in this case.
‘‘While I remain critical of Dr B’s individual appropriate decision-making, I am also critical of the inadequate systems in place at Health NZ Southern at the time to guide safe decision-making and appropriate surgical planning and support in such circumstances.’’
Health NZ Southern had since made changes including establishing a memorandum of understanding with Health NZ Waitaha Canterbury and the University of Otago concerning the supervision of overseas-trained surgeons, and the introduction of a periodic review of its neurosurgeons’ accreditation by an external peer.
Ms Cooper recommended Dr B, Dr C and Health NZ Southern each provide formal written apologies to Mr A’s family.
Health NZ Southern has been approached for comment.
