A woman who was left in agony for 12 days after her colon was mistakenly sewn shut during surgery, says she hopes doctors learn from the rare error and are quicker to believe their patients.
The Health and Disability Commissioner this week recommended two surgeons and Nelson Marlborough District Health Board apologise to Georgie Ferris for providing suboptimal care during and after the December 2014 surgery.
Ferris, who has since been diagnosed with Ehlers-Danlos syndrome, had a history of bowel motility problems when she had the surgery on December 17 at Nelson Hospital for a temporary colostomy to rest her bowel.
But during the surgery Ferris' colon was sewn shut when the wrong end was attached to the stoma - an opening in the stomach.
It meant the then 18-year-old, Year 12 Waimea College student's body could not excrete waste and she couldn't eat.
"I was just in horrendous pain. My stomach literally looked like I had a ball under the blanket. I almost felt like it was going to pop."
Ferris said the pain radiated throughout her body when she moved and though she tried to explain to doctors it felt different to any of her previous bowel obstructions they did not consider there could be a mechanical error.
In the anonymised report released on Monday, Health and Disability Commissioner [HDC] Anthony Hill said there was no stoma output in the first five days following the operation and Ferris complained of increasing pain.
In response to Ferris' 2016 complaint, the general surgeon who performed the operation [Dr B], told the HDC she took steps to check the correct end of the colon was used to form the stoma, including checking there was no twist in the bowel.
"Dr B said she did not consider it unusual there was no stoma output over this time. She explained that [Ferris'] symptoms were the same as those [Ferris] had experienced prior to the operation, and were consistent with her motility problem."
After six days of being unable to pass a bowel motion into the stoma, Ferris was given two enemas with no effect.
On Christmas Eve Ferris was given 100ml of serous fluid through the stoma, a dose of lactulose and another enema.
Again there was no effect and feeding through a nasojejunal tube [from the nose to part of the small intestine] commenced but had to be stopped after Ferris vomited.
On Christmas Day Dr B went on annual leave for four days and Ferris' care transferred to Dr C without official handover.
She was given Klean-Prep, a strong laxative, again with no effect other than to cause severe pain.
"This should have prompted earlier investigations as to a likely mechanical cause for the stoma non-function rather than the presumed continued thoughts that this was all a motility related delay to function," general surgeon Dr Mark Sanders said.
Sanders, the independent expert for the HDC, said further action was warranted by day five when enemas were not working.
Nutritional compromise, very little oral intake, vomiting, abdominal distension and the fact the laxative did not work, should also have prompted earlier action, he said.
On Boxing Day a nasogastric tube had little effect and on December 28 a Gastrografin X-ray, a special X-ray of the small bowel using dye, indicated a bowel obstruction.
A surgical registrar attempted to pass a Foley catheter down the stoma for decompression but the procedure was abandoned when resistance was felt 10cm in.
The report said Dr C stated he would usually investigate a non-functioning stoma after five days but because of Ferris' history of poor bowel motility, he did not.
On December 29, when Dr B returned, further Gastrografin was injected and it was evident there was a mechanical problem.
Ferris was rushed into emergency corrective surgery.
She said she had to endure many painful and unnecessary procedures over the 12 days as a result of Dr B's error.
"I should have been listened to at the time and especially when I explained to them that my pain was worse than any other obstruction I had ever endured," Ferris said.
"The indications of a mechanical bowel obstruction were more than blatantly obvious and I should never have been subjected to the doubt and lack of action that led to 12 days of unbelievable and incomprehensible pain and suffering."
Hill agreed. Though he accepted the error was rare and technical, likely less than 1 per cent frequency, Hill was critical that Dr B did not identify in her visual check she had used the wrong end of the bowel.
He said Dr C should have acted quicker to investigate Ferris' symptoms and that NMDHB poorly managed her post-operative care. He also noted the DHB did not carry out a serious event review of the case.
Hill recommended all three provide Ferris with formal written apologies and that the DHB audit its compliance of Health Quality and Safety Commission requirements for notification and reporting of adverse events between 2015 and 2018.
Despite the surgery Ferris said she was pleased with how her ongoing care for EDS, a connective tissue disorder, was being managed at Nelson Hospital.