An ultrasound showed part of the woman's thyroid was ‘largely replaced’ by a nodule and there was no tissue in the other part of her thyroid. File image / 123RF
A woman was left with “constant pain” in her neck after a doctor removed part of her thyroid and told her she wouldn’t need medication as the other side of the gland would “pick up the job”.
But in reality, the left side of her thyroid had no tissue, a fact that had been detected on an ultrasound but overlooked by the doctor who told the woman was “intact and functioning”.
The Health and Disability Commissioner has found flaws in the doctor’s handling of the situation, including post-operative follow-up when the woman experienced complications.
The doctor has since apologised, saying he would not wish the experience on anybody, and “deeply regrets this”.
According to a decision released today, the woman (referred to as Ms B) went to her GP in May 2019 with swelling on her neck after commencing a mood-stabilising medication six weeks earlier.
A blood test showed normal thyroid activity, but an ultrasound showed she had “no thyroid tissue appreciated in her left thyroid bed” and that her right thyroid lobe was prominent and largely replaced by a nodule (abnormal tissue growth).
The doctor, referred to as Dr A, saw Ms B at a general surgical clinic in June 2019, recommending surgery.
She said he did not mention the left side of her thyroid gland and that she asked, “valid questions prior to surgery”, adding that Dr A responded “arrogantly”.
Ms B said tDr A told her before surgery that he “hoped that the left side thyroid lobe would pick up the job of a complete thyroid and no thyroid replacement medication would be required”.
She told the commissioner that due to a chance of cancer (while being unaware of the ultrasound findings of the left thyroid lobe), she decided to opt for surgery to remove the right thyroid lobe.
A surgical procedure was performed to remove the right lobe in August 2019.
Dr A then wrote to her GP, saying she wouldn’t need ongoing follow-up, and that he would arrange a repeat thyroid function test in two to three months.
However, Ms B requested a follow-up appointment with Dr A a month after surgery, saying she now had a very swollen face with swelling under the chin, around the jaw and sides of her face.
She said Dr A examined her and reassured her that the swelling in her face was normal and would go down. Dr A’s impression was that it probably represented fluid build-up as a result of scarring and swelling from the surgery.
A fortnight later, she went to a duty GP, complaining of “constant pain” in her left neck area and “heavy feet”, and that pain-relief medications did not help the symptoms.
She went to her GP three days later complaining of fatigue, a stiff/swollen neck, and feeling “not right since surgery” two months earlier.
Her GP took a blood test which showed critically abnormal thyroid stimulating hormone levels.
Dr A said he was in an operating theatre when he received a phone call from Ms B’s GP in October 2019, saying he did not appreciate how unwell she was, and informing Dr A of the blood test results.
Dr A told the commissioner that he later recognised that “he missed an opportunity to support her by not arranging an immediate review in his clinic”.
It was two months later when he saw her and told her GP that he had reviewed her preoperative ultrasound and noted she had “quite a small thyroid on the left side”, so he wondered whether her hypothyroidism had been “uncovered by removing the right lobe”.
Dr A wrote in his clinic letter that he apologised to Ms B for not having identified the small left thyroid lobe earlier, although that was disputed by Ms B, who said she was not informed until three months later.
Ms B’s thyroid function tests were reviewed at the December appointment and Dr A documented in a further letter to her GP in January 2020 that he would get the ultrasound between “now and my next clinic to see what kind of thyroid remnant she has on the left side”.
Ms B said that during her ultrasound in February 2020, she “realised what had happened” when the sonographer could not locate her left thyroid lobe, and at the following appointment in March 2020 she demanded that Dr A explain why he failed to tell her that her left lobe was non-existent.
Her support person at the appointment said that following the second ultrasound when Ms B “realised that Dr A either did not know or did not recall that she had no left side thyroid tissue, Dr A left the room for some time to consult or review notes and Ms B was very upset”.
From their perspective, Dr A had apologised but also seemed to try to minimise the error.
Dr A continued to be involved in Ms B’s care until April 2020. Clinic notes documented Dr A was making thyroxine dose recommendations and communicating with Ms B’s GP, the thyroid blood test taken on April 7, 2020 (after Ms B’s last consultation with Dr A) being within normal range.
Dr A said he sent an email to Ms B in May 2020 to offer a written apology for failing to recognise her risk of hypothyroidism after surgery and saying that he should have recognised the symptoms at her first postoperative visit.
Ms B said she questioned Dr A’s record-keeping and the reason for overlooking the radiology finding concerning her left thyroid lobe.
She said that the right thyroid lobectomy had a significant negative impact on her health and wellbeing.
Deputy Health and Disability Commissioner Deborah James was critical of errors in Dr A’s documentation, particularly noting that he relied on his clinical documentation at subsequent appointments with Ms B.
She accepted Dr A had overlooked the finding of an abnormal thyroid lobe on the ultrasound and departed from the acceptable standard of care when he did not consider hypothyroidism as a potential diagnosis at Ms B’s follow-up appointment.
Dr A told the commissioner he sincerely apologised to Ms B.
“It has affected her greatly and required a long and difficult recovery.
“I would not wish this experience on anybody and deeply regret this. I have taken this matter very seriously and have taken this as an opportunity to reflect and learn from the events surrounding this case.”
He was told to report back to the Health and Disability commissioner with the result of an audit of the last 100 radiology reports he had signed off, and, if the audit had identified any further overlooked findings, provide a plan for follow-up and remedial actions.
Dr A was told to provide a copy of a post-operative blood-testing protocol and discharge-planning document, and report back on his enrolment in communication workshops and a mastering risk workshop.
He was told to make a presentation on a risk topic at a departmental audit meeting, confirm that the anonymised case study and learnings had been presented to his colleagues, and consider copying patients into all clinic letters so that any discrepancies in the documentation of the consultation can be identified and resolved in a timely manner.
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 Hauraki-Coromandel Post, based in Whangamatā. He was previously deputy editor of the Cook Islands News.