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Unsuccessful laparoscopic sterilisation surgery (07HDC03504)
Download Unsuccessful laparoscopic sterilisation surgery (07HDC03504) (PDF 160Kb)
(07HDC03504, 26 February 2008)
Medical officer ~ Obstetrician and gynaecologist ~ Tubal
ligation ~ Credentialling ~ Incident reporting ~ Peer review ~
Supervision ~ Recruitment ~ Medical Council processes ~
Documentation ~ Informed consent ~ Rights 4(1), 4(2), 6(1),
This inquiry examined why laparoscopic sterilisation surgery
(tubal ligation) performed by medical officer Dr Roman Hasil at
Wanganui Hospital in 2005-06 was unsuccessful for eight of 32
women. Six of those women became pregnant and were confronted with
difficult decisions. Most decided to have a termination.
On one level, what happened is simple. The medical officer did
not place clips correctly on the Fallopian tubes of eight women.
But why such a basic mistake was made - resulting in a
sterilisation failure rate of 25%, compared with an accepted
failure rate of 0.2% - is more complex.
The medical officer was an experienced obstetrician and
gynaecologist who had been head of an obstetrics and gynaecology
(O&G) department in Slovakia for six years. But from 1996 to
2005, he had a chequered work and medical registration history in
In August 2005, he commenced work as a medical officer in the
O&G department of Whanganui DHB, which for many years had been
understaffed and unable to recruit specialists. His background
should have come to light during the process of his employment and
registration in New Zealand. It did not, owing to inadequate
reference checking and credentialling.
The medical officer was granted registration by the Medical
Council within a provisional general scope of practice. Under the
terms of his registration, he was required to be supervised by the
head of the O&G department. The medical officer and his
supervisor worked in a grossly understaffed department, with a
demanding and unsustainable 1 in 2 on-call component.
From the outset concerns were raised about the medical officer.
They initially related to his competence. Then health issues
emerged. He was reported to be smelling of alcohol while on duty on
several occasions. The concerns about his competence did not abate,
and further patient and staff complaints were received. During
2006, four of the medical officer's patients returned to the DHB
pregnant following sterilisation surgery.
It was held that the medical officer did not provide services of
an appropriate standard in a number of respects. In particular, he
did not perform laparoscopic sterilisation surgery on two patients
with reasonable care and skill - his record-keeping was inadequate,
and his informed consent process in relation to another patient was
substandard. He breached Rights 4(1) and 4(2) of the Code in
relation to two patients, and Rights 6(1) and 7(1) in relation to
His supervisor was aware of concerns about the medical officer,
but did not consider that he was unsafe. The supervisor was
overworked, but he followed up the concerns with the medical
officer and remained satisfied that he was performing to an
acceptable standard. In hindsight, that was an error of judgement,
but given what he knew at the time, he took reasonable actions to
supervise the medical officer.
It was held that the DHB did not fulfil its duty of care. The
DHB breached Right 4(1) by its lack of care in employing the
medical officer, by failing to have a system in place to monitor
his practice effectively, and by failing to respond to his
competence and health concerns in a timely and effective
Good policies and procedures are to no avail if they are not
followed in practice. It is unacceptable that the sterilisation
failures were not exposed by any of the DHB's systems for quality
assurance, such as incident reporting, audit, peer review and
supervision. Despite the raft of quality assurance policies and
procedures at the DHB, they were not followed, and chance played a
large part in exposing the cluster of failed sterilisations.
This report highlights the need for hospitals to have effective
processes in place to identify and respond to concerns about a
clinician's practice. Staff need to be aware of the processes, and
adequately trained and supported in their implementation.
Management and clinical leadership are critical. It is tempting to
cut corners when faced with endemic workforce shortages. But a lack
of care in appointing staff, and failure to identify problems and
act decisively, results in unnecessary harm to all involved - to
patients, to doctors, and to public confidence in a local
It is the Medical Council's responsibility to ensure that
doctors registered in New Zealand are competent and fit to
practise. This includes responsibility for registering new
international medical graduates and for reviewing reports from its
regulatory supervisors during the provisional registration period.
However, the Council's responsibility does not detract from a DHB's
obligation to properly credential and monitor the performance of an
Given New Zealand's increasing dependence on newly registered
international medical graduates to staff hospitals (especially in
smaller centres) it is essential that supervision is not "watered
down". Effective supervision is critical for safe health care. The
Medical Council has a key role to play in training and supporting
regulatory supervisors, and employing DHBs must appropriately
support and resource clinical supervision.
Public hospitals face major pressures related to workforce and
training, distribution of skills and skill mix, and financial
resources. These 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
co-ordination and collaboration across DHBs, is essential to
maintain safe, good quality services in the face of these