According to the decision, which was released today, the woman was admitted to Palmerston North Hospital with abdominal pains in 2020.
It was recorded that she did not have a history of gallstones, and there was no mention that a cholecystectomy (surgical removal of the gallbladder) had occurred in 2005.
During her admission, an ultrasound identified the presence of at least one gallstone and the gallbladder was noted to be “not well distended” with a “thickened wall”.
She was admitted to the ICU ward a couple of days later because of respiratory distress and severe pancreatitis. Again, her history was noted, but there was no mention of surgical removal of the gallbladder.
A CT scan of her abdomen and pelvis that day noted the gallbladder was "shrunken" with at least one gallstone seen.
Cooper said in her decision that the woman had three sets of clinical records.
The first set was sent to the ICU ward the day after the CT scan and included reference to the cholecystectomy in 2005.
A consultant general and gastrointestinal surgeon, referred to as Dr C, told the deputy commissioner that the medical history was obtained both from A and from her electronic clinical records, which recorded hypertension, ischaemic heart disease, and a hemicolectomy in 2005. A hemicolectomy is a surgical procedure where part of the colon is removed.
Dr C said that, based on the ultrasound and CT scan and with no known history of gallbladder or gallstone surgery, he assumed that the cause of her severe pancreatitis was gallstones.
The woman’s daughter, referred to as Ms B, told the commissioner that her mother’s records should have been looked at more closely, given her understanding that a cholecystectomy is common during bowel surgery.
The woman’s condition improved and she was put on a waiting list for laparoscopic cholecystectomy surgery, the surgical removal of the gallbladder using a minimally invasive approach, following a consultation with Dr C.
All three sets of her medical records were provided to the hospital’s pre-admission clinic three months later and the woman attended a pre-anaesthetic clinic, where her previous hemicolectomy surgery was recorded.
But, again there was no record of the cholecystectomy.
Abandoned surgery
The consultant general surgeon performed the surgery about a month later.
He said the woman had had a thorough history taken and there was no record of the cholecystectomy.
He said that after commencing the laparoscopy it became apparent that a cholecystectomy had been performed previously and the surgery was abandoned.
He searched the electronic system, which showed no previous documentation of a cholecystectomy. However, the hard-copy notes recorded that a hemicolectomy and a cholecystectomy had been performed at the same time.
Dr C said the information had not been made available to him by the woman or by the hospital booking team.
He said electronic records at Health NZ MidCentral had been in use since about 2010 and that there were few, if any, electronic clinical records available prior to that time.
One of the woman’s first electronic clinical records was a letter dated February 2013 following a clinic consultation by the surgeon who had undertaken the hemicolectomy in 2005, and the letter made no mention of the gallbladder removal that occurred at the same time, he said.
He said it was not routine practice to review clinical records of patients on a waiting list in the time interval between placement on a waiting list and the surgery date unless there was a clinical problem, which was not the case.
The electronic records, digital images, and imaging reports did not highlight the previous gallbladder removal, he said.
Dr C said that hard-copy clinical records were often stored in several sets or volumes, which may or may not be available at the time.
Older volumes were frequently stored off site and often it was the latest records that were made available.
a Palmerston North Hospital staffer contacted her brother
Health NZ told the commissioner that a formal incident report was completed following the abandoned surgery and that a review was undertaken by the clinical lead for surgery.
Following the woman’s discharge, her daughter told the deputy commissioner that a Palmerston North Hospital staffer contacted her brother.
The staffer outlined several inaccurate details about the incident and their mother’s medical history, including that the scans were misinterpreted by a radiologist; her clinical notes did not mention the gallbladder removal in 2007 and that she had not been admitted to Palmerston North Hospital previously prior to her admission.
Health NZ told the Deputy Commissioner that it was unable to identify the staff member who made contact with the woman’s son, and it apologised for the inaccurate information provided.
A subsequent review found that the paper clinical files with documentation of the gallbladder was contained in one of the clinical files, which was available for staff to review in the intensive care unit and available to the surgeon and the preoperative clinic.
Records in the electronic clinical portal went back only to 2012 and the hard-copy clinical records prior were not captured in the clinical portal, reviewed by the anaesthetist only during the abandoned surgery.
Hard-copy documentation of the gallbladder surgery was not reviewed by the surgeon prior to the surgery, nor at the preoperative clinic. The surgeon and anaesthetist had relied on the findings of scans performed prior to surgery.
Apology and recommendations
It was later recommended staff take all steps to ensure that both electronic and hard-copy files are reviewed sufficiently to enable informed decision-making; staff be educated on policy and procedure for open disclosure and how to record clinical incidents on software, and that phone calls to patients be recorded on a telephone consult form and filed in clinical records.
Health NZ told Cooper that it unreservedly apologises to the woman and her family for the care she received.
Cooper said multiple staff members had failed to review the hard-copy clinical notes adequately.
“I consider that this case highlights the importance of significant details of a patient’s clinical history such as previous surgeries being readily available and visible to treating clinicians.
“I note that Health NZ told the Health and Disability Commissioner that it is now working through the implementation of scanning hard-copy clinical files into the electronic clinical portal, and I consider this to be an appropriate course of action to minimise the possibility of a recurrence of such an event.”
Cooper recommended Health MidCentral prepare and present an anonymised case study based on the events for the wider education of medical staff at Palmerston North Hospital and provide an update to the commissioner on the implementation of scanning hard-copy clinical files into the electronic patient clinical portal within three months of the decision.
Cooper recommended Health Mid Central also provide an apology to the woman and her family.
Al Williams is an Open Justice reporter for the New Zealand Herald, based in Christchurch. He has worked in daily and community titles in New Zealand and overseas for the last 16 years. Most recently he was editor of the HC Post, based in Whangamata. He was previously deputy editor of Cook Islands News.
