A woman in her 60s has been left unable to walk and in ongoing pain after an orthopaedic surgeon wrongly inserted screws into her spine during an operation.
Now, more than three years on from the tragic surgery, details of the case can be revealed while the Medical Council of New Zealand will decide if the surgeon is fit to continue his practice.
"[Her] life changed forever at the hands of a qualified surgeon. She is now a T1 Paraplegic fully dependent for all life cares, described by the Spinal Unit Consultant as a 'tragic surgical outcome'," the woman's daughter said in the report.
Medical Council Chair, Dr Curtis Walker, told the Herald today the council took public safety very seriously and were in the process of considering a number of options.
"The options available to the Medical Council include considering whether or not any immediate action is required to protect public health and safety, for example suspending the doctor's ability to practise or imposing conditions on their practice.
"The Medical Council also considers whether or not it needs to undertake an assessment of the doctor's competence."
It comes after the surgeon and District Health Board have been found in breach of the Code of Health and Disability Services Consumers' Rights for the surgical error, a report released today shows.
The names of the woman, daughter, surgeon and DHB are not reported for legal & privacy reasons.
The investigation by New Zealand's Health and Disability Commission came after the woman had a spinal fusion operation in May 2017.
The report said there were issues with the computer navigation system.
The surgeon told HDC: "[U]nfortunately we did not get good guidance from the computer navigation system which at the end of the day is provided to try and give much more accurate and complication free screw placement, however no system is entirely foolproof in this setting."
The woman spent 10 days in hospital after the surgery, suffering from chest pain, before she was sent home.
Two months later, she suffered a fall at home and was rushed to the emergency department where a CT scan revealed the screws in her spine were misplaced and she had urgent surgery to try fix it.
However, she soon lost her ability to walk and the pain continued.
"She was too sore to lie flat," the report said.
The surgeon said in the report: "I … do accept responsibility for the very sad outcome."
"I would like to offer my sincere regrets to [woman's] family and to [the woman] herself in particular for the unfortunate outcomes from treatment of a complex spinal problem."
Deputy Health and Disability Commissioner Rose Wall, who led the investigation, was critical of the surgeon's errors, saying: "As a result of the misplaced screws in the first operation, [the woman] had to undergo further surgeries and treatment, and suffered ongoing pain and loss of mobility."
"Accordingly, I find that [the orthopaedic surgeon] did not provide services to [the woman] with reasonable care and skill."
She recommended that the surgeon report back to the HDC regarding the changes he plans to undertake and how this has changed and/or improved his practice, and apologise to the woman and her family.
Wall also advised the Medical Council of New Zealand consider whether a review of the orthopaedic surgeon's competence is warranted.