Names have been removed (except Dunedin Hospital/Otago DHB) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Otago District Health Board
A Report by the Health and Disability Commissioner
Mr A had tetraplegia following an accident. Because of the tetraplegia, he had a permanent suprapubic urinary catheter which he managed with the assistance of community nursing staff.
On 10 June 2005, the catheter required changing, and Mr A's nursing staff were unable to replace it. Accordingly, he presented at Dunedin Hospital Emergency Department. Attempts were made to introduce a suprapubic catheter, but this proved difficult. Eventually, the on-call surgical registrar inserted the catheter, and Mr A was admitted to hospital to be observed.
On the morning of 12 June 2005, Mr A's condition rapidly deteriorated. He was subsequently admitted to intensive care, but he died later that day.
This report considers the standard of care provided to Mr A from 10-12 June 2005. In particular, it focuses on the attempts made by medical staff to introduce a suprapubic catheter in ED, and the availability of senior medical staff advice.
Mr A (dec), Consumer
Mrs A, Complainant/Consumer's wife
Dr B, ED registrar
Dr C, ED consultant
Dr D, Urology consultant
Dr E, Surgical registrar
Otago District Health Board, Provider
Complaint and investigation
On 28 August 2007 the Health and Disability Commissioner (HDC) received a complaint from Mrs A about the services provided to her husband, Mr A, by Dunedin Hospital. The following issue was identified for investigation:
The appropriateness of the care provided to Mr A by Otago District Health Board from 10 to 12 June 2005.
An investigation was commenced on 22 May 2008.
Information was reviewed from Mrs A, Otago District Health Board (Otago DHB) and the Coroner. Two sets of independent expert advice were obtained from urologist Dr Michael Rice: preliminary expert advice (Appendix 1), and further advice after ODHB had been formally notified of the investigation (Appendix 2). Expert advice was also provided to the Coroner by urologist Dr Edwin Arnold (Appendix 3).
Information gathered during investigation
Mr A suffered an accident when he was aged 42. This resulted in a fracture of his 7th cervical vertebra, and left him with tetraplegia. Since that time, he had lived at home assisted by community nursing staff. Because of his paralysis, Mr A had a suprapubic catheter, which was changed approximately every two weeks by the nursing staff who assisted him with his care. A registered nurse (RN), who was one of the nurses who regularly cared for Mr A, advised the Coroner that, in the past, it had proved necessary for a new catheter to be inserted by a urologist in Dunedin Hospital Emergency Department (ED).
ODHB provided a copy of an operation note of 30 January 2001. The procedure performed was the re-insertion of a suprapubic catheter by urologist Dr D. The operation note states:
"[Mr A] is a high cervical spine tetraplegic who has had [a] suprapubic catheter as part of his ongoing treatment. This fell out recently and attempts to re-insert this in the Emergency Department failed. He developed quite significant rise in blood pressure secondary to autonomic dysreflexia and this precluded distending his bladder any further to facilitate … suprapubic catheter insertion. Hence an indwelling catheter was inserted and he was booked urgently for [suprapubic catheter] insertion."
10 June 2005 ― attendance at ED
On 10 June 2005, Mr A's catheter started to leak, and it was decided that it needed to be changed. A registered nurse, one of Mr A's community nurses, removed the catheter, but she was unable to introduce a new one. It was agreed that Mr A would go to Dunedin Hospital ED for this procedure to be performed. He drove himself to hospital, and the community nurse called ahead to the hospital to advise Mr A was on his way.
The ED record states that Mr A arrived at 1.18pm with a blocked suprapubic catheter. Clinical observations were performed at 1.45pm (his blood pressure was raised at 151/106mmHg, pulse 59).
Mr A was assessed by ED registrar Dr B at 1.21pm. Dr B stated that Mr A told him that he would need an introducer to insert the new catheter, but despite attempts with two sizes of catheter, Dr B was unable to introduce the catheter.
Having used a needle and syringe to withdraw some urine from Mr A's bladder to release the pressure, Dr B attempted to insert a different type of catheter (Cooke's). This attempt also proved unsuccessful, and Dr B decided to contact the urology registrar. However, the urology registrar was not on duty as he was due to be on call that night.
Dr B then contacted the ED consultant on duty, Dr C.
Dr C examined Mr A using an ultrasound machine, "which confirmed he still had residual urine in his bladder and that the top of the bladder lay above the catheter tract". Dr B made a further unsuccessful attempt to introduce the catheter. Dr C and Dr B concluded that a specialist urology opinion was required.
Call to on-call urology consultant
Dr C telephoned the on-call urology consultant, Dr D. Dr C was informed over the telephone by a third person (possibly an anaesthetist) that Dr D was unable to talk on the telephone. Dr C explained the clinical situation to the third person, and understood that the information was relayed to Dr D. Through the same third person, Dr C was advised to contact the on-call surgical registrar.
In his statement dated 15 July 2005 to the subsequent ODHB internal investigation, Dr D stated that he had no recollection of this call. He advised that he "was not aware of [Mr A's] presence in the hospital until about 11.20pm when he was rung at home by [Dr E]". This statement was repeated in ODHB's letter to HDC of 14 September 2007. However, in a letter of 16 June 2008, Otago DHB stated that, when he was contacted by ED staff, Dr D "advised that a new suprapubic catheter be inserted through the existing suprapubic catheter tract". This is consistent with Dr D's evidence to the Coroner, in which he stated that he instructed that the suprapubic catheter be replaced, but he did not recall whether he had been told there had been previous attempts to insert it.
However, in an email to HDC dated 23 July 2008, Dr D gave a contrary statement:
"I am not able to recall if I had asked for the surgical registrar on call to be contacted and that a new suprapubic catheter be introduced through the existing tract."
In any event, the upshot of Dr C's indirect communication with Dr D was that Dr C then contacted Dr E, the on-call surgical registrar.
While they waited for Dr E to arrive, Dr B and Dr C made a further attempt to introduce the catheter. Dr B stated that he was "unable to enter the bladder as [he] was uncomfortable with the amount of resistance to the insertion of the [catheter]". He abandoned the procedure.
Insertion of catheter by on-call surgical registrar
At the time, Dr E had had six months' experience of urology, and was an advanced trainee (registrar). However, he had never before inserted a suprapubic catheter in a patient with tetraplegia. In a statement to the Coroner, Dr E described his care of Mr A:
"I was … called and came to see [Mr A]. On examination he appeared to be in some mild discomfort. His abdomen was soft and there was some suprapubic tenderness to palpation.
I used the ultrasound machine and could easily identify the suprapubic tract with some tissue clearly visible obstructing the tract midway down.
The bladder was also easily visualised. Often after a catheter has been removed for some time tissue tends to fall into the tract and cause an obstruction which makes the insertion of another catheter down the tract more difficult.
[Mr A's] carer was there and she indicated to me she normally changed the catheter and [Mr A] acknowledged that fact. It seemed appropriate at the time to see if she could replace a catheter. She was unsuccessful.
As I had done six months as a Urology Registrar at North Shore and Auckland Hospitals I was familiar with suprapubic catheterisation as I had done a number of these procedures before.
I prepped [Mr A's] suprapubic region with aqueous povidine iodine and draped the region. Initially I asked the carer if she could hold the ultrasound probe for me but then [Dr C] became available and volunteered to assist me. He used the ultrasound scanner to demonstrate to me the tract and the top of the bladder. This was to allow me to make sure that I did not go too superior and miss the bladder.
I used a long angiocath needle and placed it 2 to 3cm in the tract to demonstrate the direction of the tract. Usually I would use a fine spinal needle in a virgin abdomen but as part of the tract was already there I felt a stiffer needle would help demonstrate the tract better to me. I also felt that reinserting the suprapubic down the same tract would be the safest place to go as the bladder would be nicely scarred up against the anterior abdominal wall. This would make it less likely to cause any bowel injury.
I slowly pushed the needle in aspirating as I went. Eventually, some blood stained urine was aspirated confirming the needle was in the bladder, I was not surprised that the urine was blood stained as [Dr B] had aspirated some urine before and may have caused some bleeding in the process which would not be uncommon. Also during the process of me using this angiocath needle I may have also caused some bleeding which also would be expected.
Often using an angiocath needle requires quite a degree of force to insert the trocar into the bladder and to the lay person this may appear to be quite aggressive or forceful but is in fact both necessary and normal.
I then used a 20 French Cooke's peel away catheter (a catheter with which I am very familiar) and inserted it along the same direction. Every centimetre or so I would remove the central trocar to see if any urine would come back. Again a certain degree of force was used to insert this Cooke's peel away down the tract. Eventually after several checks as I inserted the catheter blood stained urine came out of the catheter which confirmed the catheter was in the bladder. A urinary bag was attached and I left instructions with nursing staff to irrigate the bladder clear of clots and that he could be discharged later that evening. I also advised [Mr A] to drink plenty of fluid and warned him of potential clot retention."
Continued care in ED
The nursing record states that the suprapubic catheter irrigation was repeated at 4.40pm as there were blood clots in the urine bag ("blood ++").
Irrigations were performed regularly during the evening, and at 7.40pm Dr E was asked to review Mr A because of continuing haematuria and swelling of the lower abdomen. Dr E queried a haematoma after the suprapubic catheter insertion. He requested a haemoglobin check and an ultrasound scan to check for signs of bleeding.
At 9pm, Mr A's blood pressure dropped to 54/34, and he was transferred to the resuscitation bay. He was described as "pale and obviously distressed" by a registered nurse. A litre of IV fluids was prescribed to be administered quickly (it was administered in 45 minutes from 9.30pm to 10.15pm). The registered nurse stated that Mr A "improved quickly", and he was transferred to the radiology department to have the ultrasound scan, which was performed at 9.45pm. The ultrasound was reported as showing "no subcutaneous haematoma".
Admission to ward
Following discussion with the nursing staff (who were concerned about Mr A's condition), Dr E contacted Dr D. It was agreed to admit Mr A, and that Dr D would review him the following day. Mr A was admitted to a ward at around 2am.
Overnight, Mr A's urine output and blood pressure were monitored, and it was planned that he would be discharged the following day.
11 June 2005
Dr D reviewed Mr A in the morning on his ward round. He recalls:
"I met [Mr and Mrs A] the next day in [the Ward]. I went through his clinical notes and told him that he had a blockage of the catheter tract, which was opened up again by the catheter introducer kit, and a new tube had been put into his bladder. [Mr A] was upset about having had to wait for about three hours in the Emergency Department, before he was seen by the staff. He said, during this period, his blood pressure shot up to 130/100 … due to a condition called autonomic dysreflexia, a condition that can happen in patients with tetraplegia, especially involving the upper segments of the spinal cord. He said that he was aware of the rare complication of the blood vessels inside the brain bursting, due to this increase in blood pressure, which can sometimes lead to potential complications like stroke. I agreed that this was the case and reassured him that I would speak with the senior staff in the Emergency Department, and make sure that patients with high tetraplegia be seen immediately, following their presentation to the Emergency Department, whenever the reason for their admission was something to do with bladder or bowel. I told him that he should remain in the hospital for at least another 24 hours, because of the fact that he had some infection, which was being treated with intravenous antibiotics. [Mr A] asked me why the re-insertion of the catheter into his bladder had not been done under general anaesthetic. I told him that insertion or re insertion of tubes into the bladder was a very minor procedure and were usually done under local anaesthetic and that it was indeed a blind procedure and damage to the lining of the bladder can happen, even in experienced Urologist's hands. I told him that if I had attended to [Mr A], I would have re-inserted a catheter much in the same way as the Surgical Registrar. [Mr and Mrs A] appeared to be satisfied with my explanation."
Mr A's condition improved over the day. The clinical record describes Mr A having a good urine output, and his urine was "clearing". A result of the blood test taken at 1.45pm showed that Mr A's haemoglobin had fallen to 100, from 147 the previous day.
12 June 2005
No changes in Mr A's condition were reported overnight.
At 9.10am, Mr A's condition suddenly deteriorated, and the resuscitation team was called. His condition remained critical, and he was transferred to the intensive care unit.
A CT scan of Mr A's chest and brain were performed, and showed a "very large blood clot, blocking the main blood vessel to the lungs, and evidence of damage to [Mr A's] brain following the period of lack of blood circulation, when his heart [twice] stopped temporarily". In discussion with Mr A's family, it was decided to withdraw treatment and Mr A died at 2.40pm on 12 June 2005.
Other relevant matters
ODHB's internal investigation report concluded:
"[A]lthough [Mr A's] death was regrettable we have not found any evidence that it resulted as a consequence of any staff member working outside their limits of competency or outside the bounds of reasonable practice."
On-call consultant availability
Otago DHB was asked if it is acceptable to the DHB that on-call surgical staff may be simultaneously operating in a private facility, off site. Otago DHB stated that "it is the expectation that when on-call consultant staff will respond in a timely manner". The job description for a consultant urologist states that a consultant must "participate in the emergency on-call roster for Urology (to be available by telephone within 10 minutes, and available to come into the hospital within 20 minutes)".
The findings of the internal investigation stated:
"The panel notes that if a Senior Medical Officer has commitments in private practice there exists opportunity for a conflict of interest should they be required to have a presence at Dunedin Hospital in relation to on-call commitments. The situation seems more problematic for a surgeon. They cannot be scrubbed in theatre in both institutions at the same time."
ODHB Chief Executive Officer Brian Rousseau commented:
"I appreciate that the issue of an on call consultant working at a private facility (and performing an elective procedure) whilst on call appears inconsistent with the need for availability. However, I believe that the matter is complex, especially so for smaller district health boards who may have many speciality services with only one or two (actual) consultant staff or low full time equivalent arrangements (sometimes further complicated by joint academic appointments).
Because of a small pool of consultants in some specialities the following points require consideration:
- On-call consultants may be operating electively in Dunedin Hospital whilst on call - this may present the same circumstance as in this complaint insofar as physical availability;
- In two-consultant specialities, both consultants may be operating on the same complex case when one of them is on call;
- We should also consider what should happen when the consultant is called to the private hospital for an emergency whilst on call, or operating on an emergency case in the public hospital;
- Sometimes there may be only one consultant available for a speciality for a prolonged period of time (such as we currently have for urology whilst [Dr D] is away for 6-8 weeks); in such a case, unless the consultant closes his/her private practice, there will be times that they are working privately and on call for the public hospital. The alternative would be to shut down their private practice for this time which would not be acceptable to the consultant or their private employer;
- Employment issues, including recruitment of staff, would be made much more difficult than it already currently is for DHBs such as Otago should private practice not be available to consultants, or if on-call arrangements precluded them attending reasonable private work.
Furthermore, problems with access to on-call consultants are very rare events despite the current arrangements some hold in private practice. We also enjoy a high degree of cooperativeness due to flexibility in our arrangements with consultants which is of benefit to our patients and our service.
Notwithstanding the above, I intend to again discuss this matter further with our Chief Medical Officer … . The outcome of the review of our on-call arrangements will be communicated back to you by 19 December 2008."
The Coroner obtained expert advice from Dr Edwin Arnold, urologist and Medical Advisor at Burwood Hospital specialist spinal unit (see Appendix 3). Dr Arnold advised that the standard of care for Mr A was "less than ideal", giving as examples the decision to persist with attempts to replace the suprapubic catheter rather than a urethral catheter "as a temporising measure", and the decision to replace the suprapubic catheter without a general or spinal anaesthetic.
The Coroner, in a decision dated 28 August 2008, found:
"I find that the deceased [Mr A] died at Dunedin Hospital on the12th day of June 2005, death being due to acute cardiovascular collapse complicating severe pulmonary artery embolism due to deep vein thrombosis involving the pelvic plexus veins in association with basilar artery thrombosis. I find that these complications originated from bleeding which occurred when a supra-pubic catheter was inserted after several unsuccessful attempts to the previous day.
On viewing the whole of the evidence and the submissions received I consider that there are aspects of the deceased's care that justify a recommendation from me. Because of the complicated nature of the evidence including the fact that it appears that there are differing views on a number of issues, I propose simply to recommend and invite the Otago District Health Board to review the whole history of this matter and to give careful consideration to whether there are aspects that require to be improved. In saying this, I am conscious of the fact that an extensive report of the Clinical Review Panel has already been carried out and I commend the hospital for taking that action. But it may be now that, following the inquest at which a large number of witnesses gave evidence and many were cross examined, … some issues have developed which now justify reconsideration. Purely as an example I suggest that consideration should be given to the situation that arose where the urology consultant on call was unavailable on that day because he was conducting surgery at a private hospital. I am not in a position to make a finding that any such issues were a cause of or contributed to the death but pursuant to s15(1)(b) Coroners Act 1988 I make the recommendation that the whole of the evidence be reviewed, with a view to reducing 'the chances of the occurrence of other deaths in such circumstances'."
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability Services Consumers' Rights (the Code) are applicable to this complaint:
Right to Services of an Appropriate Standard
(1) Every consumer has the right to have services provided with reasonable care and skill.
(5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
Opinion: Otago District Health Board - Breach
It is not my remit to ascertain the cause of Mr A's death ― that is the province of the Coroner. It is for me to decide whether Mr A was provided with reasonable care, and whether all the Otago DHB clinicians co-operated to ensure quality and continuity of care.
Standard of care
It is relevant to note an earlier event. In January 2001, after Mr A's suprapubic catheter had fallen out, it was replaced under general anaesthetic because it proved difficult to reinsert it in the emergency department. In the meantime, a urethral catheter was inserted. Understandably, Dr D may have forgotten this event from four and a half years earlier, but he performed the procedure himself.
On 10 June 2005, Mr A came to ED with a similar presentation. However, on this occasion, a number of attempts were made to insert the suprapubic catheter in ED. Dr B eventually stopped his attempts as he was uncomfortable with the amount of resistance he was encountering in his efforts to re-catheterise Mr A. Eventually, the surgical registrar was contacted as there was no urologist available to attend.
The surgical registrar, Dr E, who had never before inserted a suprapubic catheter in a patient with tetraplagia, inserted the suprapubic catheter using what he described as "quite a degree of force [which] to the lay person … may appear to be quite aggressive or forceful but is in fact both necessary and normal".
My independent expert, urologist Dr Michael Rice, stated that "the introduction of suprapubic catheters in patients with tetraplegia can have particular challenges for a medical practitioner". However, neither Dr E, nor Dr B, nor Dr C discussed these particular challenges with Dr D or any other urologist prior to the attempts to insert the suprapubic catheter.
In my view, the medical staff should not have continued in their attempts to insert the suprapubic catheter once the first attempt was unsuccessful. No thought appears to have been given to inserting a urethral catheter and arranging the suprapubic catheter insertion for a later time. According to Dr Rice and to the Coroner's expert, Dr Arnold, a urethral catheter should have been inserted once it had proven difficult to insert the suprapubic catheter. It is notable that this is precisely what occurred in January 2001.
Specialist medical staff advice
When the ED medical staff decided they needed the advice of a specialist urologist, they contacted the urology registrar but he was not rostered on duty. When the urology consultant was contacted, Dr D was found to be operating in a private hospital, and unable to speak to Dr C directly. The subsequent conversation was relayed through a third person.
When asked by HDC whether it was acceptable for on-call surgical staff to be simultaneously operating in a private facility, Otago DHB responded that in this case "the physical presence of a consultant was not deemed to be necessary".
Whatever the views of Otago DHB management, I do not consider it acceptable that an on-call urologist can be operating at a private facility at the same time as he is required to provide support and advice to a public hospital. Dr D's job description required him, when on call, to be "available by telephone within 10 minutes, and available to come into the hospital within 20 minutes". In my opinion, by participating in an operation off-site (which appears to have been a planned, possibly non-urgent procedure), Dr D was not as available as he needed to be. Nonetheless, I accept that Dr D was simply following an accepted practice for ODHB on-call consultants.
I note that the Otago DHB internal investigation made a recommendation on this point, as it noted that there could indeed be a conflict, particularly for surgeons, who cannot be "scrubbed-up" for surgery on two sites at once. However, it is unclear what action Otago DHB has taken in response. I endorse the Coroner's view that "consideration should be given to the situation that arose where the urology consultant on call was unavailable on that day because he was conducting surgery at a private hospital". In my view it is a situation that needs to be remedied.
While I appreciate the complexities explained by Otago DHB in its response to the provisional opinion, I remain of the view that Mr A's care was jeopardised by the unavailability of specialist medical advice, as a consequence of the simultaneous, scheduled absence of both the urology registrar and the urology consultant.
I conclude that it was inappropriate to make continued attempts to introduce the suprapubic catheter once initial attempts had failed. It was also unsatisfactory that the surgical registrar continued with the attempts to introduce the suprapubic catheter despite having no previous experience of performing this procedure for a patient with tetraplegia. While individual members of staff must consider their own practice in light of this case, in my opinion the clinical team as a whole let Mr A down. In these circumstances, Otago DHB breached Right 4(1) of the Code.
When urology specialist advice was required, it could not be obtained from a registrar, and the on-call urologist was operating off-site in a private facility. The request for advice and the response were relayed through a third party. Specialist advice was required, but for all practical purposes it was unavailable, with no urology registrar on duty, and the on-call urology consultant operating in another hospital. The registrar's absence was known to Otago DHB, and the DHB condones the practice that resulted in the consultant's absence. While the outcome may not have been affected had Dr D spoken directly with one of Mr A's attending doctors, on the day, the clinicians did not work together effectively to provide good quality care for Mr A. Accordingly, Otago DHB breached Right 4(5) of the Code.
Dr D has given varying accounts of his recollection of his conversation with Dr C on the evening of 10 June 2005. As neither of them made a contemporaneous record of their contact, it is not surprising that Dr D's recall is imprecise. I am also concerned that Dr E did not record the care he provided to Mr A and the subsequent orders to the nursing staff.
A medical practitioner has a responsibility to "keep clear, accurate, and contemporaneous patient records that report the clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed". On the available evidence, Dr E, Dr D and Dr C did not comply with this professional responsibility. I make a recommendation on this point below.
Otago DHB performed an internal investigation after Mr A's death, and concluded that there was no evidence that any staff member worked outside their limits of competency. It is clear that much energy was expended on this internal investigation, with statements being taken from a number of staff. However, it is remarkable that no concern was raised about the appropriateness of the continued attempts to pass the suprapubic catheter; that inserting such a catheter in a patient with tetraplegia has "particular challenges" (as stated by Dr Rice); or that such a procedure was performed by at least one medical practitioner with no prior experience. It is also notable that there is no reference to the absence of any clinical record of the evening of 10 June 2005 by Dr C or (more importantly) Dr E. These are all important aspects of Mr A's care which were missed by the internal investigation.
Otago DHB response to provisional opinion
Otago DHB accepts that it breached the Code of Health and Disability Services Consumers' Rights in relation to Mr A's care, states that "[t]he issues of documentation have been noted by those involved in [Mr A's] care", and notes the critique of its internal investigation. Otago DHB provided an apology for Mrs A.
I recommend that Otago DHB review the on-call requirements of senior medical staff in relation to simultaneous operating at another facility, and advise HDC of the outcome of the review by 19 December 2008.
- A copy of this report with details identifying the parties removed, except the experts who advised on this case and the names of Otago District Health Board and Dunedin Hospital, will be sent to the Minister of Health, the Director-General of Health, the Royal Australasian College of Surgeons, the New Zealand Private Surgical Hospitals Association, the Association of Salaried Medical Specialists and all district health boards, and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
Preliminary expert advice from urologist Dr Michael Rice: (pdf)
[refer to pdf document to view image]
Further expert advice from urologist Dr Michael Rice: (pdf)
[refer to pdf document to view image]
Expert advice provided to the Coroner by Dr Edwin Arnold: (pdf)
[refer to pdf document to view image]
 "The symptoms of autonomic dysreflexia are caused by the inability of two normally balanced feedback loops to communicate.
Blood pressure rises as a direct consequence of constriction of blood vessels caused by local feedback loops from the spinal cord which is receiving warning signals of bladder distension (the commonest cause of autonomic dysreflexia). The adrenal gland is also stimulated, and the resulting rising levels of adrenaline in the blood are detected in the brain.
The brain responds by trying to inhibit further secretion of adrenaline by activating the parasympathetic component of the nervous system that results in dilation of blood vessels and slowing of the heart.
Because of the damage in the spinal cord these signals are not received below the level of damage, apart from the heart which has a nerve supply independent of the spinal cord. Their effect is expressed above the damage. Their effect is not inhibited and intense dilation of blood pressure results, causing intense headache." (ODHB internal investigation report.)
 Clinical observations were next performed at 7pm.
 The time of the call was not recorded.
 Dr D had one Friday afternoon session every month when he operated at another hospital in Dunedin.
 Dr E advised the Coroner that, since this incident, he has never inserted another suprapubic catheter.
 No clinical record was written by Dr E describing the care he provided to Mr A.
 Normal: 130-180.
 Dr D's statement to the Coroner, dated 8 July 2005.
 Good medical practice ― A guide for doctors (Medical Council of New Zealand, 2005).