A woman who lost sensation in her feet after a spinal operation was let down by her surgeon and a registered nurse, the Health and Disability Commissioner has found.

Details of an investigation, released today, said the woman, a 69-year-old medical practitioner herself, received "sub-optimal care" in relation to her "deteriorating" condition after her surgery.

The nurse and surgeon both failed to respond "appropriately" after the woman suffered complications as a result of elective spinal surgery at a private hospital.

The Health and Disability Commissioner has recommended the nurse and surgeon apologise in writing to their patient and both should be subject to an independent review of their practise.


The woman went into surgery on May 27, 2009, for an operation on her spine.

That evening, the orthopaedic surgeon, who specialises in spinal surgery, and his anaesthetist reviewed the woman's condition.

The registered nurse assigned to her care recorded the woman had lost sensation and movement in her feet at midnight.

She continued to monitor the woman two-hourly but did not report her observations to the duty manager or surgeon.

Early the next day, the surgeon and his anaesthetist reviewed the woman again, noting her loss of movement and sensation.

The surgeon did not document his findings or provide further instructions to the nursing staff about ongoing monitoring of the woman.

There was a disagreement about when a theatre was available and the woman was finally operated on again at 3.28pm that day.

Following that surgery, the woman spent two weeks in a public hospital and a month in a spinal unit for rehabilitation.


She requires intermittent catheterisation and manual bowel evacuation, the Health and Disability Commissioner said in its report.

She also suffers ongoing pain in her feet and perineum and cannot sit for any length of time without pain.

The commissioner found the nurse breached the code of conduct by "failing to report the changes in the woman's neurovascular status, failing to record all assessments and failing to undertake a critical evaluation ... or make a plan of action".

The surgeon also breached the code by "failing to provide appropriate postoperative care, failing to comply with the professional standards in relation to clinical documentation and failing to communicate effectively with the private hospital staff".

The commissioner also recommended the surgeon complete a communications skills course.

The private hospital was not in breach, the commissioner said.