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Management of gynaecological patient (14HDC00991)
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(14HDC00991, 28 November
Laparoscopic surgery ~ Injury ~ Deterioration ~ Information ~
Documentation ~ Rights 4(1), 4(2)
A woman in her early fifties, who had a left ovarian cyst, was
booked to have a laparoscopy performed by an obstetrician and
gynaecologist at a public hospital.
The woman saw the obstetrician/gynaecologist preoperatively, and
consented to surgery. There is no documentation on file outlining
that operative risks specific to the woman were discussed with her.
The obstetrician/gynaecologist said that he discussed specific
risks of surgery with the woman and provided her with a leaflet.
The woman said that the obstetrician/gynaecologist broadly
discussed risk and that she could not recall whether any leaflet
was provided to her.
Tumour marker blood test (CA125) results were ordered by the
obstetrician/gynaecologist and a risk of malignancy index (RMI)
calculated in the afternoon following his consultation with the
woman. The obstetrician/gynaecologist telephoned the woman about
the tumour marker result (which was negative) he had received. The
obstetrician/gynaecologist could not recall whether he discussed
the RMI score (99). The woman told HDC that he did not discuss it.
The telephone call and RMI calculation were not documented.
The surgical procedure was complicated owing to adhesions. An
operative injury to the bladder occurred, which was repaired by a
urologist called to assist in theatre. The
obstetrician/gynaecologist handed over to a second obstetrician and
gynaecologist. The woman had a difficult postoperative course. A
senior house officer reviewed the woman over the weekend. The
senior house officer communicated the possibility of a ureter or
bowel injury, instigated a number of investigations, and brought
her concerns to the attention of the second
obstetrician/gynaecologist, on three occasions, the first by
The following morning, the second obstetrician/gynaecologist
reviewed the woman. His impression was that, potentially,
medication side effects explained her nausea. A differential
diagnosis of bowel injury was made. The second
obstetrician/gynaecologist did not order investigations.
By 12.15am two days later, the woman's urine output had
decreased. It had been "minimal to none" over the previous four
hours. The laboratory informed the senior house officer that the
blood cultures had grown a gram negative bacillus. The senior house
officer telephoned the second obstetrician/gynaecologist. He did
not review the woman or arrange a surgical review.
It was considered at an early morning team meeting handover that
the woman must have a bowel perforation. She was referred to the
surgical team. She had a laparotomy that day, and faecal
peritonitis from two holes in the sigmoid colon was discovered. The
woman had further surgery including a colostomy, and then
additional surgery 48 hours later. She was cared for in ICU and
then transferred to the ward. She later developed a fistula from
her bladder to the rectal stump. The woman was later discharged to
the care of surgeons in another region.
While it was accepted that the first obstetrician/gynaecologist
telephoned the woman about the tumour marker result, criticism was
made that he discussed the proposed surgery with the woman that
morning without the knowledge of important clinical factors (the
tumour marker result and a quantified risk of malignancy) - factors
that were relevant to a preoperative discussion and her
consideration of whether or not to proceed with surgery.
Although it was accepted that some of the first
obstetrician/gynaecologist's peers would consider it appropriate
for him to have commenced the procedure given his level of skill,
adverse comment was made that he did not appreciate, or think
critically about, the potential surgical difficulties he might face
given the woman's history of extensive adhesive disease.
The first obstetrician/gynaecologist did not meet his
obligations to keep clear and accurate clinical and surgical
records. Accordingly, he failed to comply with professional
standards, and breached Right 4(2).
Postoperatively, there was a delay in the second
obstetrician/gynaecologist recognising that the woman might have a
bowel injury, given that the possibility had been brought to his
attention on more than one occasion, particularly once the blood
culture results were available, and he made a decision not to
review her or refer her for surgical review. Accordingly, the
second obstetrician/gynaecologist failed to provide services to the
woman with reasonable care and skill and, therefore, breached Right
It was found that the DHB had overall responsibility for the
series of deficiencies in care experienced by the woman. In
addition, at the commencement of the first
obstetrician/gynaecologist's employment, and at the time of the
woman's surgery, the first obstetrician/gynaecologist was not made
aware of RANZCOG guidelines pertaining to performing advanced
operative laparoscopy. The DHB's surgical consent form in use at
the time had no space for the purpose of recording risks specific
to the patient. There were several administrative shortcomings
identified in this case. The DHB therefore failed to ensure that
the woman was provided with services with reasonable care and
skill, and breached Right 4(1).
It was recommended that the first
a) Have an independent colleague
review a random selection of his surgical consent forms from the
last 12 months to report on whether specific surgical
risks/concerns for each patient are written on the consent form,
and report the results to HDC.
b) Provide HDC with a copy of the
template (as recommended by his supervisor) used in his dictation
in relation to information discussed in the consent process, to be
dictated at the beginning of the operation note and also
handwritten on the operation note.
c) Provide a formal written
apology to the woman.
It was recommended that in the event that the second
obstetrician/gynaecologist returned to New Zealand to practise, the
Medical Council of New Zealand consider whether a review of his
competence is warranted.
The Commissioner made a series of detailed recommendations to
the DHB including requesting an update report on the progress and
effectiveness of all steps taken to improve services as a result of
this case, including its changes to practise, changes to policy,
and the results of surveys and audits of staff compliance with
The Commissioner also recommended that RANZCOG consider whether
the wording of a relevant consensus statement concerning advanced
operative laparoscopy requires revision.