Before the surgery, the woman told the anaesthetist and Te Whatu Ora about her concerns regarding morphine.
There was documented evidence of the patient's past adverse reactions to morphine in clinical notes, as well as on her medical emergency bracelet.
The woman said morphine could cause her heart rate to slow to an abnormally low rate.
However, the anaesthetist gave the woman 3mg of morphine.
He thought it would help control her pain after surgery. He also believed the small dose and constant monitoring would allow him to establish if it was a safe drug for the woman.
The woman never gave her consent to the anaesthetist to do so, which James said must be in writing.
If a general anaesthetic is given, the Code of Health and Disability Services Consumers' Rights stipulates that consent must be in writing as a safeguard.
After the surgery, the woman was told she had been given morphine.
James found Te Whatu Ora did not breach the Code, as the errors that occurred did not indicate broader systems issues, and appropriate policies had been in place.
However, James said Te Whatu Ora staff could have done more to advocate on behalf of the woman to prevent the use of morphine without her consent.
She recommended the anaesthetist undertake further education and training on informed consent and report back to the Health and Disability Commissioner on completion of the training.
She also recommended Te Whatu Ora use an anonymised version of this case for the education of its staff.
James said the process for pre-operation checks could be streamlined, and steps taken to ensure staff could advocate for patients in theatre when and as required.
