File photo. Photo: Unsplash/ Piron Guillaume
A man died after inexperienced and uncredentialled surgeons performed brain surgery on him in 2019.
The coroner referred the matter to the Health and Disability Commissioner to investigate.
Aged Care Commissioner Carolyn Cooper found poor systems at Health New Zealand Southern led to the dangerous situation.
In findings, released Monday, Cooper said the 77-year old man, referred to as Mr A, went to the Health New Zealand Southern public hospital in 2019 after suffering a heart attack.
Mr A then developed headaches and vision problems, and it was found he had a benign tumour in his pituitary gland that was bleeding.
Initially it was treated with medication and clinicians monitored his symptoms. However, within a week the neurosurgery team felt his vision had deteriorated to such an extent that urgent surgery was needed.
The surgery was led by a neurosurgeon referred to as Dr B.
Dr B knew he did not have the experience to perform the surgery, so he sought permission for another neurosurgeon, Dr C, to assist, Cooper said.
Dr B's usual on-site supervisor, Dr D, was on annual leave at the time.
Dr C was not an employee of HNZ Southern and did not have the credentials to operate at the hospital.
It had also been a year since he had performed surgery and more than two years since he had completed this type of surgery - a pituitary tumour resection, Cooper's report said.
Dr D said he would normally expect Dr B to seek advice on all cases outside his scope of experience.
However, Dr B said he had not been told he had to consult with his supervisor or the neurosurgical team about his clinical decisions and, on the rare occasions he did, it was at his own discretion.
He said Dr D and Health New Zealand Southern knew that was his usual practice.
During surgery, a decision was made to extend the procedure with Dr C to remove more tumour tissue.
Dr C said his intention was to remove the tumour to prevent new bleeds and the need for further surgery.
While Dr C was doing this there was extensive bleeding, which was most likely from damage to an artery that supplied blood to the brain and head.
Mr A died after a heart attack and losing a significant amount of blood.
Cooper said Dr B, Dr C and HNZ Southern breached Mr A's right to services provided with reasonable care and skill.
"It is concerning that Health NZ Southern did not have adequate plans or protocols in place to supervise and support staff in Mr A's case. While I remain critical of Dr B's individual preoperative decision-making, I am also critical of the inadequate systems in place at Health NZ Southern at the time to guide safe decision-making and appropriate surgical planning and support in such circumstances," said Cooper.
"I consider that the lack of appropriate protocols strongly contributed to the dangerous situation that eventuated in which Dr B, a surgeon requiring supervision, did not seek advice from his neurosurgical colleagues at Public Hospital 2."
The impromptu involvement of a non-Health NZ Southern employee to support Dr B was an unusual situation and she would expect there would be clear and explicit disclosure of this to the patient, Cooper said.
Instead there was no mention of Dr C's involvement in the clinical records or consent form.
"The absence of such documentation is concerning, and I find it more likely than not that Mr A was not adequately informed of Dr C's participation and role in the operation. As such, it is not evident that Mr A received the information that a reasonable consumer in his circumstances required before giving informed consent."
HNZ Southern had brought in a standardised list of tasks neurosurgeons cannot perform since Mr A's death.
The South Island Neurosurgery Service must now also spend six weeks at HNZ Waitaha-Canterbury Neurosurgical Unit to better coordinate and develop collegial relations between the teams.
Dr B had left New Zealand and his practice was now confined to his subspecialty.
Dr C now limited himself to research and teaching in New Zealand and clinics overseas. He had not been performing neurosurgical interventions since Mr A's death.
Health New Zealand Chief Medical Officer Southern Dr David Gow said Health NZ Southern accepted the HDC's findings in relation to this patient's care in 2019.
"We are sincerely sorry the patient's experience and acknowledge that our failures have caused significant distress for the patient's whānau.
"We have sent a written apology to the patient's whānau, and we are open to directly engaging with them to discuss our own internal findings into this incident."
Health NZ Southern accept all the Commissioner's recommendations and were working to implement them.
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