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Clinical networking (09HDC01207)
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(09HDC01207, 20 December
Public hospital ~ District health board ~ Hemicolectomy
~ Clinical networking between hospitals ~ Patient safety ~
Referrals between provincial and regional centres ~ No
A man complained about the management of complications when his
mother had a right hemicolectomy in a
provincial hospital, and developed symptoms postoperatively. The
surgical team at the hospital decided to take a conservative
approach to treatment, and did not re-operate straight away. The
woman's condition did not improve. The surgical team decided that
she should be fed intravenously, to rest her bowel. However, she
developed an infection, and it was decided to stop the intravenous
feeding and resume an oral diet.
The surgeons then decided to re-operate. During the operation,
they discovered that there was a leak in the colon where it
appeared that a staple had fallen out. Postoperatively, the woman
seemed to recover. However, five days after the surgery, she
suddenly became unwell, vomited and had a cardiac arrest. Despite
attempts to resuscitate her, she died.
Professor Bryan Parry, a general surgeon, provided expert
advice. He noted that although he would have managed the care
differently, the treatment was of a satisfactory standard
"In my Institution's Morbidity and Mortality Meeting there would
have been a robust professional discussion about her management
along the lines above. Although disagreement would have been
expressed, it is unlikely that the surgeon would have been censured
due to the acceptable divergence of opinion in the management of
anastomotic leak in general, and the undoubted complexities of
[this patient's] case. There is no reason to suppose that [the
surgeon's] management was negligent in any way."
As a general statement for how similar cases should be managed
in the future, Professor Parry noted:
"…as these are infrequent cases, consideration of referral to a
larger regional centre should have been considered. In mitigation
there is no 'Intestinal Failure Unit' formally established or
funded in NZ, although Auckland Hospital has traditionally tended
to function in that capacity by default."
In light of the expert advice, it was held that there was no
breach of the Code.
It is important that clinicians in smaller, provincial areas are
able to have access to advice from, and/or referral to, larger
regional centres. Although the DHB advised that there were no
barriers to clinicians accessing advice from the regional centre,
the Commissioner asked the DHB to review its current guidelines for
referral, and to consider whether it provides sufficient
encouragement for clinicians to seek the input of other providers
beyond the local facility.
The lessons from this case are not unique. In particular, the
importance of clinical networking in the interests of promoting
patient safety has been noted previously. For example:
1. In a case involving the failure
of an orthopaedic surgeon in a small hospital on the West Coast to
refer to a larger centre, HDC recommendations included:
"I recommend that the Ministry of Health, all district health
boards and the Royal Australasian College of Surgeons (RACS) work
together to develop and implement a plan to address the issue of
credentialling surgical services provided by district health boards
(especially in remote areas or smaller centres) and the surgeons
who work in such services. This process should include
- what support services are needed before surgical procedures can
safely be undertaken in remote areas and smaller centres in New
- the need for a regional perspective on service planning and
collaboration between neighbouring district health boards."
2. One of the key messages from
the report of the Whanganui DHB/Dr Hasil inquiry was that:
"Public Hospitals face major pressures related to workforce and
training, distribution of skills and skill mix, and financial
resources. They are particularly acute in smaller centres.
Isolation is the 'kiss of death' for a clinician, a department and
a DHB. Regional and national service planning, and increased
coordination and collaboration across DHBs, is essential to
maintain safe, good quality services in the face of these
In that case, it was apparent that for the women of Whanganui, a
safe and sustainable obstetric and gynaecology service may need to
be on a regional basis.
3. In a case involving a general
surgeon undertaking rectal cancer surgery, the Commissioner
"I accept that an appropriately trained general surgeon
practising in provincial New Zealand can maintain high standards of
care if adequately supported. Provincial centres must have strong
relationships with larger centres as they inevitably face
limitations in terms of support."
These cases involve different DHBs, and different areas of
practice of medicine. However, all highlight the need for DHBs and
doctors to work collaboratively in the interests of improved
 Surgery to remove part of her
 Opinion 06HDC09552 (31 January 2008) page 38.
 Opinion 07HDC03504
(February 2008) pages 5-6.
 Opinion 07HDC17438 (21
April 2009) page 9.