Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

1. On 21 December 2020 HDC received a referral from the Office of the Coroner concerning the standard of care provided to Mr A at Health New Zealand|Te Whatu Ora Southern (Health NZ Southern) in Month1[1] 2019. Sadly, Mr A died as a result of the events outlined in this report, and I extend my sincere sympathies to his whānau for their loss. Mr A was aged 77 years at the time.

Information gathered

2. On 16 Month1 2019 Mr A presented to Public Hospital 1 and was found to have suffered a heart attack. In the days following his admission, Mr A developed headaches and vision problems. A computed tomography (CT)[2] head scan showed a pituitary macroadenoma[3] with bleeding. This was putting pressure on the optic chiasm,[4] causing Mr A’s symptoms. Initially this was managed conservatively with medication changes and monitoring of symptoms until the neurosurgery team, led by Dr B,[5] felt that Mr A’s vision had deteriorated acutely and urgent surgery for transsphenoidal evacuation of the pituitary haemorrhage[6] was indicated.
   
   
3. Dr B recognised that he did not have adequate experience to undertake this procedure. Accordingly, he sought permission (from the Service Manager, who in turn contacted the General Manager and the Chief Medical Officer) for Dr C[7] to assist with the surgery. Permission was granted for Dr C to support Dr B, although it is unclear what was communicated to Dr B in terms of the accepted scope of Dr C’s involvement in the operation.
   
   
4. The South Island Neurosurgery Service (SINS) is run out of Public Hospital 1 and Public Hospital 2. Dr B’s on-site supervisor at Public Hospital 1, Dr D, was on annual leave at the time of these events.
   
   
5. Dr B had another supervisor, Dr E, who was based at Public Hospital 2. There was also an on-call neurosurgery consultant at Public Hospital 2 available to provide advice. Dr D told HDC that it would be expected for Dr B to seek advice from an available supervisor in cases outside his scope of experience, and he understood that Dr B was not trained in pituitary surgery. Dr D told HDC that normally he checked all Dr B’s theatre lists, and operations were discussed before and afterwards. Dr E also received a copy of Dr B’s theatre lists.
   
   
6. In Mr A’s case, Dr B did not seek advice from Dr E or the on-call consultant at Public Hospital 2. Dr B said that he did not recall being informed of any requirement to consult with his supervisor, Dr D, or with the neurosurgical team at Public Hospital 2 regarding his clinical decisions, including surgical interventions. However, on rare occasions he did discuss complex cases with Dr D or the clinicians at Public Hospital 2, but this was at his own discretion and not because he was directed to by any policy or instruction. According to Dr B, Dr D and Health NZ Southern were aware that his usual practice was to make independent clinical decisions without discussion with a supervisor, and this was not questioned. Further, Dr B told HDC that he was not aware of any policy involving Public Hospital 2’s clinicians in the care of patients at Public Hospital 1. He was also not aware of any criteria or process to determine whether patients should be transferred to Public Hospital 2.
   
   
7. Dr B told HDC that there was a discussion within the local neurosurgery team regarding the potential transfer of Mr A to Public Hospital 2. This option was rejected due to the high risk of transferring Mr A, and it was considered that competent specialists who could perform the necessary operation at Public Hospital 1 were available locally.
   
   
8. The consenting process for surgery was completed by two of Dr B’s neurosurgical colleagues. According to both Dr B and Dr C, Mr A was informed of Dr C’s involvement in the procedure during a preoperative discussion with Dr B. However, this discussion was not documented, and Dr C confirmed that he did not speak to Mr A before the operation. The surgical consent form, signed by Mr A, lists the procedure as ‘Transsphenoidal evacuation of pituitary haemorrhage’. The form does not state words to the effect of ‘+/- resection of pituitary tumour’.[8] ‘Bleed’ is one of the handwritten risks recorded on the form.[9] It appears that Dr C’s participation in the surgery is not recorded in any of the consenting documentation or the handwritten surgical note.[10] I am also unable to find evidence that Mr A was informed that resection of the adenoma would be considered and attempted during the procedure.
   
   
9. Surgery to decompress the pituitary haemorrhage was performed on 21 Month1 2019. Dr B accessed the site of the tumour and spontaneous evacuation occurred.[11] The decision was then made to extend the procedure to the right of the initial opening to access and resect further tumour tissue. Dr C told HDC that his intention was to remove the tumour to prevent new bleeds and the need for further surgery in future.
   
   
10. Dr C took over as the principal surgeon and extended the dural opening[12] to the right. While Dr C was using a Kerrison Ronguer[13] to remove bone and extend the opening, extensive bleeding occurred, most likely due to damage to the right internal carotid artery.[14] Dr C told HDC that he is still not certain how the injury occurred. As a result of the damage to the carotid artery, Mr A suffered a cardiac arrest and significant blood loss before the bleeding was able to be controlled.
    
    
11. Subsequent testing showed that Mr A had suffered widespread loss of function on both sides of the brain due to a lack of blood flow. Sadly, Mr A passed away. Again, I offer my sincere condolences to Mr A’s whānau for this tragic and unexpected outcome.

Adverse event review

12. An Adverse Event Report (AER) was completed by Health NZ Southern. The report included the opinions of two neurosurgeons working in New Zealand — one who does not have specialist pituitary experience, and one who has extensive experience performing pituitary surgery.
    
    
13. According to the AER, this was a complex case for which Dr B required advice from his neurosurgical peers. The AER concluded that the root cause of this event was a failure by
    Dr B to contact his colleagues at Public Hospital 2 to obtain advice. According to the report, the other contributory factors were:
    
    
    1. 1. An insufficient plan or protocol being in place to manage a patient who required pituitary treatment or other complex surgery. This resulted in an inexperienced surgeon performing urgent surgery alongside another surgeon who was not employed by Health NZ Southern. This led to the decision to attempt further tumour removal, which caused bleeding, cardiac arrest, and death;
          
          
       2. There was no protocol in place to describe the scope and type of support that could be provided by Dr C (as a non-Health NZ Southern employee) in such circumstances;
          
          
       3. The teams making up SINS were essentially independent and did not have clear pathways between them for such cases; and
          
          
       4. The accreditation process did not identify procedures Dr B was not to perform.

Independent advice

14. HDC sought independent clinical advice from a neurosurgeon, Dr Agadha Wickremesekera (Appendix A). He identified several departures from accepted standards in the care provided to Mr A by Dr B, Dr C, and Health NZ Southern. Dr Wickremesekera’s criticisms relate to the preoperative and intraoperative decision-making and the protocols in place at the time of the events. For the most part, Dr Wickremesekera’s criticisms are consistent with the findings of Health NZ Southern’s AER.
    
    
15. Dr Wickremesekera considered that Dr B was insufficiently qualified to perform this surgery, and that the supervision arrangement that utilised a non-Health NZ Southern employed surgeon was also inappropriate. Dr Wickremesekera identified this as a severe departure from the expected standard. He advised that Dr B should have sought advice on Mr A’s case from the neurosurgery team at Public Hospital 2, or another available on-call neurosurgeon in New Zealand, while Dr D was on leave. Dr Wickremesekera considers that the failure to do so was ‘one of the key points’, and a severe departure from accepted standards of care. I accept this advice, and I note that this finding is consistent with that of Health NZ Southern’s AER, which identifies this as the ‘root cause’ and key issue.
    
    
16. Dr Wickremesekera advised that it was a severe departure for Dr C to be involved in the operation as a non-employee when there were other more suitable options, such as referral to Public Hospital 2, or conservative management of Mr A’s condition. I accept this advice and note that the AER is also critical of this aspect of the care, stating that there was no sufficient plan or protocol for this circumstance, resulting in surgery being performed by an inexperienced surgeon with the support of a non-employee.
    
    
17. The clinical advice provided as part of the AER is of the opinion that the type of surgery performed should not be attempted without an on-site endovascular service.
    Dr Wickremesekera was mildly critical of Dr B’s decision to operate at Public Hospital 1. He considered that it would have been more appropriate to transfer Mr A to another neurosurgical unit where there were more experienced neurosurgeons and a skull base team available. I accept this advice.
    
    
18. Regarding the consenting process, Dr Wickremesekera noted that due to the unusual nature of having a non-Health NZ Southern surgeon present to support the main surgeon, who was inexperienced in the procedure, it would be expected that there would be a discussion with Mr A about this. It would also be expected that this discussion would be recorded in the clinical notes. An absence of such a discussion and associated documentation was viewed as significantly below expected standards. I accept this opinion.
    
    
19. Dr Wickremesekera’s opinion was consistent with the findings of the AER in that the decision to extend the procedure to remove further tumour tissue following the initial evacuation was inappropriate in the circumstances, and that this step was not necessary to relieve the compression of the optic nerves adequately. He considered this to be a moderate departure from accepted standards. I accept this advice.
    
    
20. The clinical advice contained in the AER noted that use of a Kerrison Ronguer is appropriate for enlarging a bony opening, but it would be unconventional and potentially dangerous for this tool to be used to extend the dural opening. The advisors strongly suspected that the wording used to describe this stage of the surgery was misleading, and that it was unlikely that this occurred. Dr Wickremesekera noted the absence of a dictated operation note.[15] He advised that it would be expected for Dr B to have ensured that this was completed. Dr Wickremesekera said that he was unable to provide a detailed or conclusive opinion on the appropriateness of the surgical technique and instruments used without the benefit of a dictated operation note. Dr C told HDC that the severe bleeding occurred while he was using the Kerrison Ronguer to pull on a piece of bone, but he is not certain about the cause of Mr A’s injury.
    
    
21. Based on the information available to me, I am unable to make a finding of fact on whether a Kerrison Ronguer was used inappropriately by Dr C to extend the dural opening. However, I consider that the key event during this surgery was the decision to extend the procedure to resect further tumour tissue. If the decision to extend the procedure had not been made, surgery would not have continued following the initial evacuation, and the damage to the carotid artery would not have occurred.
    
    
22. Finally, Dr Wickremesekera considers that there was a severe departure in relation to the protocols and systems in place at the time of Mr A’s operation, noting that Dr B was inexperienced with this type of surgery, and that he did not seek advice from the neurosurgical clinicians at Public Hospital 2 or another neurosurgical unit. I accept this opinion.
    
    
23. Dr Wickremesekera was sent copies of the providers’ responses to his report and asked whether this information changed his advice. He confirmed that the opinions in his report remained unchanged.

Responses to provisional opinion

24. Mr A’s whānau was given the opportunity to comment on the ‘information gathered’ section of the provisional opinion. The comments set out in their response have been addressed in separate correspondence.
    
    
25. Dr B was given the opportunity to respond to the provisional opinion. Dr B advised that he had no comment to make regarding my decision.
    
    
26. Dr C was given the opportunity to respond to the provisional opinion. Dr C advised that he accepted my decision, and he provided further comments, which have been incorporated into this report where relevant.
    
    
27. Health NZ Southern was given the opportunity to respond to the provisional decision. Health NZ Southern advised that it accepted my findings and recommendations. Health NZ Southern’s further comments have been incorporated into this report where relevant.

Opinion: Dr B — breach

28. Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code)[16] states that every consumer has the right to have services provided with reasonable care and skill. Based on the advice provided by Dr Wickremesekera, as well as the findings of Health NZ Southern’s AER, it is evident that several aspects of the care provided to Mr A did not meet accepted standards.
    
    
29. I am critical of Dr B’s failure to seek advice on Mr A’s case, his decision to proceed with surgery at Public Hospital 1, and the intraoperative decision to extend the surgery to remove further tumour tissue.[17] I therefore consider that Dr B breached Right 4(1) of the Code.
    
    
30. Right 6(2) of the Code states that before making a choice or giving consent, every consumer has the right to the information that a reasonable consumer, in that consumer’s circumstances, needs to make an informed choice or give informed consent. Right 7(1) of the Code states that every consumer has the right to receive services only if that consumer makes an informed choice and gives informed consent.
    
    
31. Although Dr B ‘believe[s]’ he informed Mr A of Dr C’s involvement in the procedure, this is not documented in the clinical records. Dr C’s role in the surgery is not recorded in any preoperative discussion notes, Mr A’s consent form, or the handwritten operation note. I consider that the impromptu involvement of a non-Health NZ Southern employee to support Dr B, who lacked experience in the procedure, to be an unusual situation. Therefore, I would expect that there would be clear and explicit disclosure of the details of this arrangement with the patient, and detailed documentation of such discussion(s) in the patient’s records. The absence of such documentation is concerning, and I find it more likely than not that Mr A was not adequately informed of Dr C’s participation and role in the operation. As such, it is not evident that Mr A received the information that a reasonable consumer in his circumstances required before giving informed consent.
    
    
32. Furthermore, it is not recorded in the operation consent form, or preoperative discussion notes, that in addition to evacuation of the pituitary haematoma, resection of the tumour might also be attempted. The possibility of ‘severe bleeding’ is one of the risks of resection, and this is not listed on Mr A’s consent form. This was information that a reasonable consumer in Mr A’s circumstances needed to receive before giving informed consent. I therefore find that Dr B breached Right 6(2) of the Code.
    
    
33. It follows that without being adequately informed of Dr C’s involvement, and that resection of the adenoma might be attempted, Mr A could not give his informed consent to the procedure. In making the decision to extend the operation, Mr A received a procedure to which he did not consent. I therefore find that Dr B breached Right 7(1) of the Code.

Opinion: Dr C — breach

34. Based on Dr Wickremesekera’s advice, as well as the clinical reviews contained in Health NZ Southern’s AER, it was inappropriate and unnecessary for Dr C to proceed with an extension of the procedure to remove further tumour tissue after the initial evacuation. I therefore find that Dr C breached Right 4(1) of the Code.

Opinion: Health NZ Southern — breach

35. It is concerning that Health NZ Southern did not have adequate plans or protocols in place to supervise and support staff in Mr A’s case. While I remain critical of Dr B’s individual preoperative decision-making, I am also critical of the inadequate systems in place at Health NZ Southern at the time to guide safe decision-making and appropriate surgical planning and support in such circumstances.
    
    
36. I consider that the lack of appropriate protocols strongly contributed to the dangerous situation that eventuated in which Dr B, a surgeon requiring supervision, did not seek advice from his neurosurgical colleagues at Public Hospital 2. At the time, Dr B was completing a provisional vocational registration period, during which he required supervision. He told HDC that he was not aware of any requirement to consult with his supervisors or another available neurosurgeon for complex cases such as Mr A’s. This led to Dr B being supported by a non-employee to perform an urgent procedure in which he lacked experience. I am concerned about the following systems issues that allowed this situation to occur; these align closely with the contributory factors identified in Health NZ Southern’s AER:
    
    
    1. 1. No specific protocols or instructions in place setting out the expectation of Dr B, as a neurosurgeon who required supervision, to seek advice from an available supervisor or another on-call neurosurgeon for complex cases;
          
          
       2. No formalised list of procedures that Dr B was and was not permitted to perform;
          
          
       3. Inadequately established communication pathways between the two public hospitals’ neurosurgical colleagues; and
          
          
       4. Authorisation for a non-Health NZ Southern surgeon without recent pituitary surgery experience to assist an inexperienced surgeon and participate in the procedure did not follow a clear protocol, contributing to uncertainty about the non-employee’s role and scope of involvement in the procedure.
          
          
37. In light of the above systems issues evident at the time of the events, which I consider did not support appropriate supervision of staff and safe practices, I find that Health NZ Southern breached Right 4(1) of the Code.

Changes made since events

38. Health NZ Southern advised that the following changes were made after the events:
    
    
    1. 1. SINS was asked to introduce a standardised list of exclusions for neurosurgeons (tasks and procedures they cannot perform).
          
          
       2. All SINS neurosurgeons must spend six weeks at the Health NZ Waitaha Canterbury Neurosurgical Unit as part of orientation to the ‘two site one service’ structure. The aim is for staff to develop strong collegial relationships, and to facilitate communication between teams.
          
          
       3. Mr A’s case was discussed at the Neurosurgical Morbidity and Mortality Committee meeting.
          
          
       4. Health NZ Southern planned to add a section to the accreditation policy setting out that emergency accreditation of non-employee surgeons ‘must be agreed to by the Medical Director (or relevant [Clinical Director] as delegate) after discussion with the relevant Clinical Director and the [Chief Medical Officer is to] be notified. The nature of the involvement must be stated and recorded in the patient record (or in an e-mail for the patient’s clinical record) and, if possible, recorded on the consent form.’
          
          
       5. A memorandum of understanding (MOU) has been established between Health NZ Southern, Health NZ Waitaha Canterbury, and the University of Otago concerning the supervision of overseas-trained surgeons.
          
          
       6. A periodic review of the service’s neurosurgeons’ accreditation by an external peer has been introduced.
          
          
       7. The document titled ‘Neurosurgery Guidelines: Guidelines when no on-site Neurosurgeon at [Public Hospital 1]’ has been updated.
          
          
       8. All neurosurgeons at Public Hospital 1 who require supervision receive this from clinicians at Public Hospital 2.
          
          
39. Dr B told HDC that he has left New Zealand, and that his practice is now confined to his subspecialty only.
    
    
40. Dr C told HDC that he has now limited himself to research and teaching in New Zealand, and clinics overseas. Since these events, he has not been performing neurosurgical interventions.

Recommendations and follow-up actions

41. I acknowledge the changes already made by Health NZ Southern, and I am also mindful that Dr B and Dr C are no longer practising neurosurgery in New Zealand.
    
    
42. I recommend that Dr B, Dr C, and Health NZ Southern, respectively, provide formal written apologies to Mr A’s whānau for the deficiencies identified in this report. The apologies are to be sent to HDC within three weeks of the date of this report, for forwarding to Mr A’s whānau.
    
    
43. I recommend that Health NZ Southern establish a protocol to ensure that those being supervised are made explicitly aware, through written and/or verbal instructions, of the expectation that complex cases and/or areas of neurosurgery in which the clinician is inexperienced are to be discussed with a supervisor or on-call consultant. This can be included in an already established process or in a newly created process. A copy of the relevant protocol or process should be sent to HDC within three months of the date of this report.
    
    
44. I recommend that Health NZ Southern provide an update on the implementation of each of the changes it has made in response to these events (set out above), including details of any training or education provided to staff regarding the changes. This report is to be provided to HDC within six months of the date of this report.
    
    
45. In response to my provisional decision, Dr C provided a letter of apology for forwarding to Mr A’s whānau. I therefore consider that Dr C has met the relevant recommendation.
    
    
46. A copy of this report with details identifying the parties removed, except the clinical advisor on this case and Health NZ Southern, will be sent to the Medical Council of New Zealand and it will be advised of Dr B’s and Dr C’s names.
    
    
47. A copy of this report with details identifying the parties removed, except the clinical advisor on this case and Health NZ Southern, will be sent to the Royal Australasian College of Surgeons and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

Carolyn Cooper

Aged Care Commissioner