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Postoperative care of gastric bypass patient (09HDC01932)

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(09HDC01932, 28 June 2013)

General surgeon ~ Public hospital ~ District health board ~ Gastric bypass surgery ~ Vitamin deficiency ~ Multivitamins ~ Loss of vision and mobility ~ Right 4(1)

A young woman was referred to a general surgeon for consideration of gastric bypass surgery. It was noted in the referral that the woman had been diagnosed with a psychiatric condition, and that she was under the care of a private psychiatrist. It was also noted that she had gained over 40kg since being on medication for her condition. The woman attended three preoperative assessments. The surgeon did not contact the woman's psychiatrist as part of his assessment of her suitability for surgery.

The woman underwent gastric bypass surgery. By that time, her weight had increased a further 20kg. Her initial recovery from surgery was straightforward. She was reviewed by the surgeon six weeks postoperatively, at which time she was prescribed multivitamins. Patients who have had gastric bypass surgery are known to be at risk of vitamin deficiencies because of their restricted diet, and therefore need to take multivitamins on an ongoing basis.

Over several weeks, the woman presented at the public hospital nine times. Her symptoms invariably included abdominal pain, nausea, and vomiting. A range of investigations were carried out during the course of her admissions, but the cause of her symptoms was not identified. For the most part, she was under the care of the Upper Gastrointestinal service, but a number of other services, including dietetics, psychiatry, and pain management, were also involved. The woman was not prescribed multivitamins during her admissions to the public hospital.

The surgeon was aware of the woman's ongoing problems and her admissions to the public hospital, and he was in contact with clinicians there.

On her tenth admission to the public hospital, she complained of blurry vision and was reviewed by an ophthalmologist, who noted paralysis of the muscles responsible for eye movement, and a reduction in visual acuity. A neurology review indicated thiamine deficiency and a Wernicke's type encephalopathy. The woman's sight and mobility have been permanently harmed.

It was held that the surgeon did not adequately assess the woman's suitability for surgery. He failed to obtain a formal psychiatric or psychological assessment, or consult her psychiatrist. The surgeon failed to provide services with reasonable care and skill and, accordingly, breached Right 4(1). He was criticised for failing to take steps to arrange for the woman to have an alternative mode of administration of the multivitamins, and for failing to advise clinicians at the public hospital that he had prescribed multivitamins.

The woman was not asked whether she was taking multivitamins, and was not prescribed them during her admissions to the public hospital until her thiamine deficiency was diagnosed. In addition, there was a failure by staff at the public hospital to adequately assess her nutritional status in light of her limited oral intake, due to ongoing nausea and vomiting. In the circumstances, the District Health Board failed to provide services with reasonable care and skill and, accordingly, breached Right 4(1). Other aspects of the care provided by the DHB were also criticised.

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