The Commissioner received a complaint from a consumer's daughter. The complaint is that:
Following the amputation of three toes from the consumer's right foot, the surgeon failed to arrange:
- Psychological support
- Orthotic services
The complaint was received on 3 October 1997 from the consumer's daughter. An investigation was commenced and information obtained from:
- The Complainant
- The Provider / Surgeon
The Surgeon and the private Hospital provided clinical notes that were viewed as part of the investigation. The Commissioner received advice from a general surgeon, a vascular surgeon and a physiotherapist.
Outcome of Investigation
The consumer's general practitioner referred her to the provider, a vascular surgeon, at a Hospital outpatients' clinic for pain in her legs, buttocks and groin on walking and the absence of a femoral pulse in her left leg. The complainant reported that her mother waited two months for this appointment, and during that time her condition deteriorated significantly.
The Surgeon saw the consumer in mid-March 1997 and made a clinical diagnosis of aortic occlusion. He advised the Commissioner that he therefore offered her urgent investigation and management at the public Hospital. The Surgeon stated that the consumer requested treatment in the private sector but the complainant disputed this, saying her mother was informed it would be several weeks before an x-ray could be arranged if she used the public health system. For this reason her mother opted to have an x-ray in the private sector.
The complainant wrote that following the cardioangiogram, the Surgeon informed her mother the only theatre time he could get was at the private Hospital. She had believed she would need to go privately only for the x-ray, not the actual treatment. But, given the pain she was in, she felt she had no choice but to go along with his arrangements. The complainant reported that at this time the consumer was in such severe pain, morphine had to be used for pain relief.
The consumer underwent arteriography at a private facility the next day and this confirmed the aortic occlusion. Six days later the consumer had an aorto-bifemoral graft. The Surgeon reported she made an uneventful recovery but some days later, her second, third and fourth toes of her right foot became gangrenous. These three toes were amputated under local anaesthetic eight days after the graft.
The complainant reported that the day after the amputation, the Surgeon removed the bandage for the first time and then left the room, leaving the consumer without support to face the results of the surgery. The complainant said that it took her mother some time to get over the shock of both the amputation under local anaesthetic and the first glimpse of her foot following that surgery. The complainant stated that the Surgeon did not arrange psychological support to assist her mother to come to terms with her loss.
In reply, the Surgeon stated it is not usual practice to provide psychological support to a patient who has undergone the minor amputation of three toes. The Surgeon further stated the consumer did not demonstrate any particular concern in this regard, or request such support.
In the nursing notes for the day after the amputation, the consumer's emotional state is described as "tired, but bright" and later in the evening as "bright and cheerful, relaxed and comfortable". Subsequent descriptions of her emotional state were similar (although the notes include the comment two days after amputation of "more acceptance of surgery") until her discharge four days after the amputation.
When the consumer was discharged, the complainant reported the Surgeon did not arrange follow-up support and therefore the consumer's husband had to change dressings "on stumps that were still bleeding" and her mother was left having to learn how to walk without three toes. The complainant considers that her mother was entitled to both physiotherapy and orthotic support.
The Surgeon responded by saying that when the consumer was discharged from hospital, she was well and independently mobile, that there were no clinical indications for physiotherapy, and that it is not usual practice to provide this. The nursing notes for the day prior to discharge stated she was confident in mobilising and on the day of her discharge, the consumer was reported as being "happy". There is reference to her receiving post- operative physiotherapy on two occasions prior to the amputation and no reference to her receiving physiotherapy after the later amputation surgery.
In response to concerns raised about the failure to consult an orthotist the Surgeon stated "there is no specific orthosis required for a patient who has had toe amputations, and it is not usual clinical practice to [make a referral]".
Following response to Provisional Opinion
In January 1999, the Commissioner formed a provisional view that the Surgeon should have ensured that a physiotherapist was involved in the consumer's care. This opinion was based on advice received from a surgeon. However the provider/Surgeon in this case disputed this view by saying that he did not consider it usual practice to have a physiotherapist before and after surgery of this nature and submitted a second opinion from a vascular surgeon which supported his view.
The Commissioner then sought a second opinion from an independent vascular surgeon who stated:
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
Right to Services of an Appropriate Standard
3) Every consumer has the right to have services provided in a manner consistent with his or her needs.
Opinion: No Breach
In my opinion, the Surgeon did not breach Right 4(3) of the Code of Health and Disability Services Consumers' Rights by not arranging psychological support, orthotic support and physiotherapy.
My advisor stated it is not usual practice to arrange psychological support following this kind of operation unless there are particular circumstances that make such support necessary. The hospital notes support that such circumstances were not present. My advisor stated that doctors and nurses are expected to perform this supportive role. In view of the consumer's emotional state both after the surgery and at the time of her discharge, in my opinion the Surgeon did not breach Right 4(3) of the Code of Health and Disability Services Consumers' Rights when he did not arrange psychological support for the consumer.
I have received advice that when the second, third and fourth toes are removed, leaving the first and last toes intact, an amputee would usually not require special footwear and a referral to an orthotist would not be necessary.
Similarly, a referral to a physiotherapist is not indicated in a situation such as that of the consumer.
In my opinion, the Surgeon did not breach Right 4(3) of the Code of Health and Disability Services Consumers' Rights when he did not refer the consumer to an orthotist and a physiotherapist.
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