The woman in her sixties underwent elective surgery at Hawke's Bay Hospital. Photo / NZME
A woman who underwent surgery to relieve her back pain suffered an injury on the operating table, which left her dependent on a wheelchair.
It was not the first thing to have gone wrong with the operation at Hawke’s Bay Hospital that day – an earlier mix-up had led to her sister being prepared for surgery and taken to the anaesthetic room.
The mistake was discovered in time and the right woman was operated on, but her spinal cord was injured, which led to a total loss of motor and sensory function in her legs.
She now has no movement or sensation, other than nerve pain in her left leg, below the L2/L3 area of her lower spine.
She also has impaired bowel and bladder function and uses a wheelchair.
The woman, who is in her sixties, suffered the injury during an operation at the hospital in Hastings in 2020.
The identities of the injured woman and the orthopaedic surgeon who operated on her have been anonymised in a Health and Disability Commissioner’s (HDC) report released today.
They are referred to as Mrs A and Dr B.
Dr B and Health NZ Te Matau a Māui Hawke’s Bay, which runs the hospital, have both been found to have breached patient rights.
The HDC report on the incident also mentions that the woman’s sister was mistakenly prepared for the operation.
She happened to be in the hospital for back pain on the same day and had to tell the surgeon a mistake had been made when he began to talk about the operation.
The sister, who is the woman’s twin with the same date of birth, had already been taken from day surgery into the anaesthetic room before the mistake was picked up.
“The error was not detected until Dr B came to talk about the incision to start the surgery and Mrs A’s sister pointed out that they had made a mistake and had taken the wrong family member in for surgery,” Deputy Health and Disability Commissioner Vanessa Caldwell said in the report.
Mrs A had previously had an operation on her back, in 2016, for a herniated disc but continued to experience significant back pain.
In 2019, she discussed with Dr B having an operation to remove pressure on the nerves and spinal cord.
The surgery involved an OLIF (Oblique Lateral Interbody Fusion), which minimises cutting to muscles and uses a single port to access the disc space, fill it with bone material, and then fuse the bones of the lumbar spine.
“Cages” were used to hold the bone graft material – devices placed between adjacent vertebrae, after removing the disc that typically occupies this space.
Following the operation, an external review and an expert’s opinion found several technical clinical issues had contributed to the injury.
These included the insufficient use of imaging technology, the incorrect positioning of the patient and instruments to avoid entering the spinal canal, and incorrect interpretation of changes in neural monitoring.
Caldwell said that she accepted these findings.
She said it was unlikely that one or two of the factors would have caused the injury, but all together they “compounded” and led to the “adverse outcome”.
“Dr B’s surgical technique was inadequate and below the expected standard of care,” Caldwell said.
She said that Dr B was a relatively newly qualified consultant undertaking complex surgery not previously performed at Hawke’s Bay Hospital.
He did not have the credentials to perform OLIF procedures.
Dr B did not seek a support surgeon for the operation, despite a recommendation that he do so.
“Overall, I conclude that Dr B failed to obtain sufficiently current information on which to make a reasonable decision to conduct this complex surgery,” Caldwell said.
“The surgical technique was inadequate, and Dr B failed to comply with the policies in place for credentialling and the introduction of the OLIF procedure,” she said.
For these reasons, Caldwell found that Dr B did not provide services to Mrs A with reasonable care, and had breached the Code of Health and Disability Consumers’ Rights.
She also found Health NZ had breached the code because of inadequate credentialling, the failure to supply a support surgeon, and for not complying with its policy for the introduction of new clinical procedures.
This, she said, was “reflective of systemic and organisational issues at Health NZ, for which it is responsible at a service level”.
She told Dr B and Health NZ to apologise to Mrs A.
Sections of the report concerning Dr B are being sent to the Medical Council of New Zealand, the surgeon’s professional body.
Mrs A’s family provided the HDC with an impact report detailing the life-changing effect of her injury, including her ongoing pain and distress.
The family said that Dr B had told them that a “blunt wedge” which had been inserted was most likely the instrument that caused the damage.
They said he told them that “the instrument [should not have been put] into such a small gap”.
Rika Hentschel, Health NZ’s Acting Group Director of Operations for Hawke’s Bay, said the agency extended its “sincere and unreserved” apology.
“We regret the deficiencies in the care that left the patient with profound and irreparable damage that has significantly impacted on her quality of life,” Hentschel said.
Hentschel said Health NZ Hawke’s Bay had made a range of improvements to systems and processes, as well as undertaking rigorous policy reviews since this “catastrophic” event.
“The number of patients who suffer harm or distress while in hospital or when using our services is small, but we take these incidents seriously – reviewing them and making changes accordingly to ensure to we keep our patients and staff safe,” Hentschel said.
Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.