The Commissioner received a complaint from a child's parents that in mid-March 1997 their son had a fractured arm plastered at a Hospital, and when the plaster was removed in early April 1997 the arm had healed at an incorrect angle. Further to this, the complaint is that two weeks after the injury the child's family were advised that a doctor had now looked at the x-ray of the injured arm and decided that a corrective procedure was required. In early April 1997 the doctor carried out the corrective procedure without adequate pain relief being administered to the consumer.
The complaint was received by the Commissioner on 2 May 1997 and an investigation was undertaken. Information was obtained from:
The Consumer's Mother
The Provider, an Orthopaedic Surgeon, Crown Health Enterprise
A Clinical Charge Nurse, Crown Health Enterprise
The consumer's medical records and x-rays were viewed and advice was provided to the Commissioner by an Orthopaedic Surgeon.
Outcome of Investigation
In mid-March 1997 the consumer, aged two and a half, fell off a slide and complained intermittently of a sore arm. The consumer was taken to a private clinic where he had his arm x-rayed and was diagnosed as having a greenstick fracture. The consumer was referred to Hospital where he was given nitrous oxide gas for pain relief, had his arm plastered and was x-rayed again with the cast on.
In early April 1997, with the agreement of the Hospital, the family's GP removed the consumer's plaster cast and found a "banana arm" On the same day the provider (an Orthopaedic Surgeon) read the x-rays of the consumer's arm and found that the post reduction x-rays showed residual angulation which required moulding to correct the angle of the consumer's arm. After reviewing the x-ray the Orthopaedic Surgeon made an appointment to see the consumer the following day "for a change of plaster cast with gentle moulding" The day after the cast was removed the child and his parents attended the appointment with the Surgeon. At the beginning of the appointment the Surgeon told the parents that he was going to give the child some nitrous oxide gas pain relief, put another cast on his arm and mould the arm. The consumer's parents explained the gas to the consumer as the "stuff that made him sing" The Surgeon then plastered and moulded the consumer's arm but no nitrous oxide gas was given although the gas bottle and equipment were present in the cubicle, having been brought in by a nurse at the Surgeon's request.
There is conflicting information about what the Surgeon said to the parents during the remoulding of the consumer's arm on that day. The child's mother recalls the Surgeon giving them information about the systems at the Hospital, including the fortnightly x-ray review system, and advised them that if they wanted top priority care they should go to a specialist or come in an ambulance as this was a teaching hospital. The Surgeon recalls informing the parents about the two weekly x-ray reviews but did not advise the Commissioner of any other systems information that he gave to the consumer's parents. There was no independent witness to the information the Surgeon provided to the parents on that day.
The consumer's parents observed their child to be in a significant amount of discomfort during the moulding process but report that he did not cry at that time because "he is a stoic child" The parents report that he was upset after leaving the hospital and is now fearful of going to the hospital to have his arm checked.
Code of Health and Disability Services Consumers' Rights
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
Right to Make an Informed Choice and Give Informed Consent
1) Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise.
Opinion: No Breach - Crown Health Enterprise
The consumer's arm was plastered about two weeks after the original injury. The plastering was carried out by a house surgeon who sought the opinion of a registrar. The post-plaster x-ray showed an alignment that looked satisfactory to the registrar. In the circumstances the alignment and plastering of the consumer's arm appeared satisfactory at the time of plastering. In my opinion the plastering by the house surgeon and review by the registrar was carried out with reasonable care and skill.
Opinion: Breach - Crown Health Enterprise
The plastering of the consumer's arm was carried out in mid-March 1997 but the post-plaster x-rays were not reviewed by the Surgeon until early April 1997. The system at the Hospital allowed for fortnightly x-ray reviews by consultants. A period of fourteen days between injury and x-ray review meant that the consultant's view that some improvement in the position of the consumer's arm was desirable did not occur until early April 1997 when the fracture had begun to unite. This system of fortnightly x-ray reviews resulted in an inappropriate standard of service to the consumer because the system did not allow the consultant to discover that moulding was indicated until fracture unity had started to occur.
Opinion: Breach - Orthopaedic Surgeon
The Surgeon informed the consumer's parents that he would give the consumer nitrous oxide for pain relief before moulding his arm. On the consumer's behalf, his parents consented to the procedure on the basis of the information provided by the Surgeon. It was the parents' understanding that the procedure they were consenting to included the administration of nitrous oxide for pain relief. The Surgeon did not administer the nitrous oxide to the consumer and neither did he ensure that any other staff member administered nitrous oxide, or any pain relief, to the consumer prior to the moulding. There was no consent given for the procedure to be carried out without the administration of pain relief, in particular nitrous oxide. The Surgeon carried out a procedure for which he did not have consent and therefore he breached Right 7(1) of the Code of Rights.
I request that the Surgeon and the Crown Health Enterprise apologise in writing to the consumer and his parents. The apology is to be forwarded to me within two weeks and I will send it on to the consumer's family. A copy will be retained on the investigation file.
Since receiving this complaint the system of x-ray reviews at the Hospital has changed and these are now conducted by consultants on a weekly basis. In view of this positive change I intend to take no further action on the matter.
A copy of my opinion will be sent to the Medical Council of New Zealand.