A surgeon performed an operation to remove the gall-bladder of a woman, despite having taken the organ out of her 13 years earlier.
Health and Disability Commissioner Anthony Hill describes the mistaken operation in a report released on his website today.
"When she saw the surgeon, the woman was unable to recall the previous surgeries she had undergone," says a summary of the report in which Mr Hill finds that the unnamed general surgeon and the Waikato District Health Board breached the code of patients' rights.
"The surgeon was sent a CT scan which identified that she did not have a gall bladder but he mislaid the scan and then failed to connect it with the patient, despite her asking about the scan."
The operation was performed by minimally-invasive keyhole surgery.
"During the surgery the surgeon thought he was operating on her gall bladder, whereas he was actually seeing her bile ducts.
"However, once the error was identified, the surgeon took appropriate action."
Mr Hill found the surgeon had failed to:
* Obtain full and accurate information about the woman's previous medical history,
* Carry out an adequate pre-operative assessment, and
* To provide adequate information to the woman prior to her consenting to undergo the surgery.
The DHB provided an incomplete set of the woman's clinical records to the surgeon. The previous surgery was recorded in the volume of notes which were not supplied by the DHB.
The DHB had a duty to ensure that the right information reached the right person at the right time.
The DHB failed to take reasonable steps to alert the woman's treating clinician to the existence of relevant clinical information, which adversely affected the care provided to her.