An elderly man died from complications of blood loss after two major blood vessels were damaged, according to an investigation that concluded his surgeon had operated "without reasonable care and skill".
Health and Disability Commissioner Anthony Hill says in a public report that the general surgeon, whose name he has withheld, and the Nelson Marlborough District Health Board breached the code of patients' rights.
He has sent the case to his prosecutor who will decide whether to lay charges against the surgeon at the Health Practitioners Disciplinary Tribunal.
The man, who had had other illnesses, underwent open - as opposed to keyhole - surgery to remove his gallbladder.
The surgeon had told him that it would need to be an open procedure because of a previous surgery.
"There is no record of any information regarding possible non-surgical treatment options being provided to the man," the commissioner's office said today. "At the time, the surgeon was subject to voluntary restrictions on his surgical practice, which the man was also not informed of."
The restrictions were a voluntary agreement with the Medical Council not to undertake keyhole gallbladder removal surgeries until completion of performance assessment process, unless a specialist surgeon was scrubbed in with him and prepared to take over the operation at any stage.
Mr Hill said the man's blood pressure started to drop about an hour after surgery. More than an hour later, the surgeon arranged an ultrasound scan, which showed internal bleeding. The surgeon decided to re-operate to control the bleeding. During this operation, a major vein was damaged, causing further blood-loss. Despite extensive resuscitation efforts, the man died.
The post-mortem found the death was caused by organ failure resulting from blood loss from the damaged vein, and from a major artery which appeared to have been damaged during the initial surgery.
The commissioner's office said there had been a number of failings.
"... a reasonable consumer in [the patient's] circumstances would expect to be told relevant information about any restrictions on his surgeon's practice, as it may have affected his decision to undergo the surgery."
The surgeon's delay before deciding to re-operate put the man at risk of harm.
The commissioner added that there had been a "lack of critical thinking" by a number of staff at the DHB regarding their failure to react to the man's deterioration in a timely and appropriate way. He held the DHB responsible for these failures.