An elderly man suffered a heart attack and significant blood loss during an operation that was undertaken by an inexperienced neurosurgeon and another surgeon who wasn’t employed at the hospital.
Tests showed the man suffered loss of function on both sides of his brain as a result of the surgery and he subsequently died.
Now, the surgeons have been criticised, with Aged Care Commissioner Carolyn Cooper saying their actions fell short of acceptable standards in their care for the man.
The commissioner was also critical of Health New Zealand Te Whatu Ora Southern and the lack of protocols, which contributed to the “dangerous” situation.
The patient, a 77-year-old man, was initially admitted to the hospital as a result of a heart attack.
But in the following days, he developed headaches and vision problems, with a CT scan revealing a benign tumour was putting pressure on the optic nerves.
As the man’s symptoms deteriorated, the decision was made to operate.
According to a Health and Disability Commissioner (HDC) decision released today, the doctor, known only as “Dr B” in the report, didn’t have the experience to conduct the operation, so he sought permission from management for “Dr C” to assist with the surgery, as his supervisor was away on annual leave.
The supervisor told the HDC he expected Dr B to have sought advice on cases beyond his experience, as he didn’t think Dr B was trained in pituitary surgery.
But Dr B told the HDC his usual practice was to make independent decisions without a clinical supervisor, which he said both his supervisor and Health NZ Southern were aware of.
The surgery took place in March 2019 and after Dr B had successfully performed the procedure, it was decided to remove more of the tumour.
The patient’s consent form didn’t mention further resection (surgery to remove tissue or part or all of an organ) of the pituitary tumour.
Dr C told the HDC this was done to stop further bleeding and prevent the need for more surgery in the future.
According to the decision, Dr C took over the surgery at this point and was working to remove the bone and widen the opening in the man’s head when extensive bleeding occurred, most likely caused by damage to an artery.
As a result of this, the patient suffered a cardiac arrest and significant blood loss before it was able to be brought under control and the man died.
The HDC sought independent advice from a neurosurgeon, Dr Agadha Wickremesekera, who identified several departures from accepted standards in the patient’s care.
This included that Dr B wasn’t qualified to do the surgery and the supervision provided by a “non-Health NZ Southern-employed surgeon” was ”inappropriate" and a “severe departure from the expected standard”.
Instead, Wickremesekera said Dr B should have sought advice from a second public hospital or another on-call neurosurgeon and considered transferring the patient to a better-equipped hospital with more experienced neurosurgeons.
He was also critical of the decision not to tell the patient of Dr C’s involvement in the case, which wasn’t recorded in the clinical notes.
“I consider that the key event during this surgery was the decision to extend the procedure to resect further tumour tissue. If the decision to extend the procedure had not been made, surgery would not have continued following the initial evacuation, and the damage to the carotid artery would not have occurred,” he said.
In her decision, Cooper, the Aged Care Commissioner, found that based on Wickremesekera’s advice, as well as the findings of the Health NZ Southern Adverse Event Review, it was evident that several aspects of the patient’s care did not meet accepted standards.
She was critical of Dr B’s failure to seek advice on the man’s case, his decision to proceed with the surgery at the public hospital, rather than transferring him to another public hospital, and the decision to extend the surgery to remove further tissue, finding Dr B breached the Code of Consumer Rights.
Cooper was also critical of the failure to record Dr C’s involvement in any of the clinical records.
“The absence of such documentation is concerning, and I find it more likely than not that [the patient] was not adequately informed of Dr C’s participation and role in the operation,” she said.
Cooper went on to say that because the patient wasn’t told of Dr C’s involvement or the attempt to further resect the tumour, the man did not give informed consent.
And given the clinical advice the commission had received, it was “inappropriate and unnecessary” for Dr C to proceed with the removal of further tumour tissue.
The decision also noted concerns that Health NZ Southern did not have suitable plans or protocols in place to supervise and support staff in the man’s case.
The lack of appropriate protocols strongly contributed to the dangerous situation that eventuated, Cooper said.
In its response, Health NZ Southern said it had made a number of changes since the incident, including creating a standardised list for all neurosurgeons, detailing tasks and lists they couldn’t perform.
Cooper recommended Health NZ Southern establish a protocol to ensure that those being supervised were explicitly aware that, for complex cases and areas of neurosurgery where they lacked experience, they needed to be discussed with a supervisor or an on-call consultant.
She also recommended that Health NZ Southern provide an update on the changes it has made to the commission within six months, including details of any training or education provided to staff.
Her decision also noted that while neither Dr B nor Dr C was still practising neurosurgery in New Zealand, they, along with Health NZ Southern, should provide apology letters to the man’s whānau.
Dr B says he has left New Zealand, while Dr C says he has limited his job to research and teaching in New Zealand and clinics overseas.
Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist for 20 years, including at the Waikato Times and RNZ. Most recently she was working as a media adviser at the Ministry of Justice.