Contents

Introduction. 

Background. 

Opinion: Health NZ — breach. 

Changes made since events. 

Recommendations. 

Follow-up actions. 

Appendix A: Independent clinical advice to Commissioner. 

Introduction

1. This report is the opinion of Carolyn Cooper, Deputy Health and Disability Commissioner, and is made in accordance with the power delegated to her by the Commissioner.
   
   
2. The report discusses the care provided to Mrs A by Palmerston North Hospital (Health New Zealand|Te Whatu Ora (Health NZ)[1] Te Pae Hauora o Ruahine o Tararua MidCentral.[2]
   
   
3. On 3 February 2021 this Office received a complaint from Ms B about the care provided to her mother, Mrs A, at Palmerston North Hospital between Month1[3] and Month6. The complaint concerns issues surrounding poor documentation and communication, resulting in unnecessary surgery for gallbladder removal, despite the gallbladder having been removed in 2005.

4. The following issue was identified for investigation:

• • Whether Te Whatu Ora|Health New Zealand provided [Mrs A] with an appropriate standard of care during [Month1] 2020 to [Month6] 2021 (inclusive).

5. The parties directly involved in the investigation were:

Mrs A                                                                     Consumer

Ms B                                                                      Complainant

Health NZ Te Pae Hauora o Ruahine

   o Tararua MidCentral                                        Provider

6. Independent clinical advice was obtained from radiologist Dr David Milne (Appendix A).

Background

7. Mrs A (then aged 80 years) was admitted to the Emergency Department (ED) at Palmerston North Hospital on 25 Month1 with epigastric pain.[4] On admission, it was noted that she had had a right hemicolectomy[5] in 2005 for ascending colon adenocarcinoma (colon cancer) as well as previous coronary artery bypass graft surgery (2007), hypertension, and ischaemic heart disease.[6] It was recorded that Mrs A did not have a history of gallstones, and there is no mention that a cholecystectomy (surgical removal of the gallbladder) occurred in 2005 at the same time as the hemicolectomy.[7]
   
   
8. During Mrs A’s ED admission, an ultrasound identified the presence of at least one gallstone. The gallbladder was noted to be ‘not well distended’ with a ‘thickened wall’, some debris within the gallbladder, and some fluid around the gallbladder.[8] The appearance was of cholelithiasis (gallstones) or probable cholecystitis (gallbladder inflammation).
   
   
9. On 27 Month1 Mrs A was admitted to the ICU due to respiratory distress and severe pancreatitis (secondary to gallstones). Mrs A’s history was noted, but again there was no mention of the previous cholecystectomy. A CT scan of Mrs A’s abdomen and pelvis on 27 Month1 noted that the gallbladder was ‘shrunken’ with at least one gallstone seen. Mrs A had three sets of clinical records, and on 28 Month1 her first set (set one) was sent to ICU, and these records included reference to the cholecystectomy in 2005. This set of records also noted previous removal of polyps in 2012 and 2018.
   
   
10. Consultant general and gastrointestinal surgeon Dr C told HDC that Mrs A’s medical history was obtained both from Mrs A and from her electronic clinical records, which recorded hypertension, ischaemic heart disease, and a right hemicolectomy in 2005. Dr C said that based on the ultrasound and CT scan and with no known history of gallbladder or gallstone surgery, he assumed that the cause of Mrs A’s severe pancreatitis was gallstones.
    
    
11. In response to the provisional opinion, Ms B told HDC that it was unfair for Dr C to say that Mrs A’s medical history was obtained from both Mrs A and the electronic records. While this may be the case, Mrs A was in ill health and in a lot of pain at the time of her admission. In addition, Mrs A had no recollection of being told that her gallbladder had been removed when she had her bowel surgery in 2005, as she was focused on her bowel surgery. 
    
    
12. Ms B also told HDC that Mrs A’s records should have been looked at more closely, given her understanding that a cholecystectomy is common during bowel surgery.
13. Subsequently Mrs A’s condition improved, and on 30 Month1 she was transferred to the surgical ward and then to the STAR wards[9] for rehabilitation. Mrs A was discharged home on 14 Month2. The discharge summary noted Mrs A’s medical history (no record of cholecystectomy), and she was put on a waiting list for a laparoscopic cholecystectomy following a consultation with Dr C.
    
    
14. Mrs A’s clinical records (sets one, two, and three) were provided to the pre-admission clinic on 22 Month5. On 23 Month5 Mrs A attended a pre-anaesthetic clinic, where the previous hemicolectomy and coronary artery bypass graft surgeries were recorded. However, again there is no record of a previous cholecystectomy.
    
    
15. Mrs A’s surgery was scheduled for 15 Month6 (later rescheduled to 20 Month6), and her clinical records (sets one, two, and three) were provided to the pre-admission clinic on 13 and 19 Month6.

Surgery — 20 Month6

16. The consultant general surgeon performed the surgery on 20 Month6. He told HDC that having reviewed the electronic records combined with the fact that Mrs A had been seen in the outpatient clinic previously, he agreed to perform the surgery, and Mrs A was placed on the semi-acute list. He told HDC that Mrs A had had a thorough history taken and there was no record of the previous cholecystectomy. He stated that after commencing the laparoscopy, it became apparent that a cholecystectomy had been performed previously.
    
    
17. He documented that immediately he searched the electronic system, which showed no previous documentation of a laparoscopic cholecystectomy. However, the hard-copy notes record that a hemicolectomy and a cholecystectomy had been performed at the same time. He stated that this information was not made available to him by Mrs A or by the booking team.

Clinical records

18. Dr C told HDC that electronic records at Health NZ MidCentral have been in use since 2010–2011 and that there are few, if any, electronic clinical records available prior to that time. The clinical portal is used to access all clinic letters, assessment reports, peri-operative records, laboratory results, discharge summaries, medical imaging reports, as well as digital images. One of Mrs A’s first electronic clinical records is a letter dated 13 February 2013 following a clinic consultation by the surgeon who had undertaken the hemicolectomy in 2005, and this letter makes no mention of the gallbladder removal that occurred at the same time.

19. Dr C told HDC that it is not routine practice to review clinical records of patients on a waiting list in the time interval between placement on a waiting list and the surgery date unless there is a clinical problem, which was not the case for Mrs A. All relevant clinical records and imaging would be reviewed by the operating surgeon immediately prior to the operation, particularly if the operating surgeon is unfamiliar with the case, as was the case here. Unfortunately, the electronic records, digital images, and imaging reports did not highlight the previous gallbladder removal. Dr C stated that hard-copy clinical records are often stored in several sets or volumes, which may or may not be available at the time. Older volumes are frequently stored off site and often it is the latest records that are made available.

Events following surgery

20. Health NZ told HDC that a formal incident report was completed, and the incident was given a provisional severity assessment code (SAC) 3 rating[10] and categorised under the Te Tāhū Hauora|Health Quality and Safety Commission (HQSC) national adverse events policy as an ‘always report and review’ event.[11] Health NZ told HDC that a 72-hour review of the incident was undertaken immediately by the clinical lead for surgery.

Communication following discharge

21. Ms B told HDC that her brother was contacted by a staff member from Palmerston North Hospital on 29 Month6. The staff member outlined several inaccurate details about the incident and Mrs A’s medical history, which included the following:

• • The scans were misinterpreted by the radiologist;
  • Mrs A’s clinical notes did not mention the gallbladder removal in 2007;
  • Mrs A had not been admitted to Palmerston North Hospital previously prior to her admission in Month1.

22. Health NZ told HDC that it was unable to identify the staff member who made contact with Mrs A’s son, but it apologised for the inaccurate information provided.
    
    
23. On 25 [Month7] Dr C met with Mrs A and her family and apologised for the error. Health NZ also met with Mrs A and her family to formally acknowledge what had occurred and to apologise and provide them with a copy of the 72-hour report.

Serious adverse incident review

24. A serious adverse incident review was completed on 10 May 2021. The review found that the paper clinical files with documentation of the gallbladder removal in 2005 is contained in set one of the clinical files, which was available for staff to review in the intensive care unit and available to the surgeon and the preoperative clinic. The records for Mrs A in the electronic clinical portal go back only to 2012. The hard-copy clinical records prior to 2012 are not captured in the clinical portal and were reviewed by the anaesthetist only during the abandoned surgery.

25. Unfortunately, the hard-copy documentation of the gallbladder surgery that occurred in 2005 was not reviewed by the surgeon prior to the 2021 surgery, nor at the preoperative clinic. The surgeon and anaesthetist relied on the findings of the ultrasound scan of the abdomen performed on 26 Month1, and the CT abdomen and pelvis findings performed on 27 Month1.
    
    
26. Mrs A’s past medical history was reviewed by the medical practitioners via the clinical portal electronic clinic letters and investigative reports from radiology and the laboratory. However, the clinic letters on the clinical portal record the right hemicolectomy in 2005 with no mention of the cholecystectomy.
    
    
27. Open disclosure of the abandoned surgery to Mrs A and her daughter did take place immediately postoperatively. The review concluded that there was a delay in reporting the incident on Riskman[12] due to the surgical registrar not being trained in the use of Riskman.
    
    
28. The review made the following recommendations:

• • Staff to take all steps to ensure that both the electronic and hard-copy file have been reviewed sufficiently to enable informed decision-making;
  • Education for staff on policy and procedure for open disclosure and how to record clinical incidents on Riskman; and
  • Phone calls to patients to be recorded on a telephone consult form and filed in the clinical records.

29. Health NZ told HDC that it unreservedly apologises to Mrs A and her family for the care
    Mrs A received.

Responses to provisional opinion

Ms B

30. Ms B was provided with an opportunity to comment on the ‘information gathered’ section of the provisional opinion and considers the facts gathered to be accurate. Ms B’s additional comments have been incorporated throughout this report where relevant.

Health NZ

31. Health NZ was provided with an opportunity to comment on the provisional opinion, and it advised that it had no comment to make regarding the contents of the report or the findings. Health NZ advised that it is working through the recommendations and has since provided an apology to Mrs A and her family.

Opinion: Health NZ — breach

32. First, I acknowledge the distress that these events have caused Mrs A and her family. After careful review of the information gathered over the course of this investigation, I have concerns about the care provided to Mrs A. I acknowledge that multiple staff were involved with Mrs A both during her admission in Month1 and prior to her surgery on 20 Month6, and, in my view, the responsibility for the deficiencies in care lay with Health NZ, as outlined below.

Review and management of clinical records

33. Mrs A was admitted to Palmerston North Hospital on 25 Month1. Her record on admission contains no mention of the cholecystectomy that took place in 2005. However, set one of Mrs A’s records were sent to ICU on 28 Month1, and these records included reference to the cholecystectomy in 2005. Full sets of Mrs A’s records were provided to the
    pre-admission clinic on 22 Month5 and again on 13 and 19 Month6.

34. There were several missed opportunities by staff to review Mrs A’s records over this time. Her records containing reference to the earlier cholecystectomy were available both when Mrs A was admitted to ICU and at the pre-admission clinic. While I acknowledge that an ultrasound and CT scan both referred to a gallbladder (discussed below), a proper review of Mrs A’s hard-copy notes would have identified the earlier cholecystectomy. I am critical that this did not occur, and that Mrs A underwent an unnecessary and avoidable procedure. I accept that the information about her gallbladder surgery was in hard-copy form, and I am concerned that significant details of Mrs A’s history were not readily available to treating clinicians.
    
    
35. Health NZ stated that the records in the electronic clinical portal for Mrs A go back only to 2012, and the hard-copy clinical records prior to 2012 are not captured in the clinical portal. Mrs A’s past medical history was reviewed by the medical practitioners via the clinical portal electronic clinic letters and investigative reports from radiology and the laboratory. Health NZ stated that the clinic letters on the clinical portal record the right hemicolectomy in 2005 but no mention of the cholecystectomy. Health NZ told HDC that the cholecystectomy was coded using ICD-10 coding[13] and provided a copy of the clinical coding information recording this and the hemicolectomy.

36. While I acknowledge that multiple staff members failed to review Mrs A’s hard-copy clinical notes adequately, I consider that this case highlights the importance of significant details of a patient’s clinical history such as previous surgeries being readily available and visible to treating clinicians. I note that Health NZ told HDC that it is now working through the implementation of scanning hard-copy clinical files into the electronic clinical portal, and I consider this to be an appropriate course of action to minimise the possibility of a recurrence of such an event.
    
    
37. I find that Health NZ breached Right 4(1)[14] of the Code of Health and Disability Services Consumers’ Rights (the Code) due to multiple staff failing to review Mrs A’s records adequately and because Health NZ did not ensure that significant details of Mrs A’s history were readily available to clinicians. This meant that Mrs A underwent surgery unnecessarily.

Communication — other comment

38. Ms B told HDC that following Mrs A’s discharge from hospital, her brother was contacted by a staff member from Palmerston North Hospital on 29 Month6. The staff member outlined several inaccurate details about the incident and Mrs A’s medical history. Health NZ told HDC that it was unable to identify the staff member, but the serious adverse event review made a recommendation that telephone calls to patients be recorded on a telephone consult form and filed in the clinical records. Whilst I cannot make a finding on the content of the conversation with Ms B’ brother, I am satisfied that the steps taken by Health NZ to address the issues with telephone communications identified after the serious adverse event review were appropriate.

Ultrasound and CT interpretation — no breach

39. During Mrs A’s admission to ED, an ultrasound identified the presence of at least one gallstone. A CT scan of Mrs A’s abdomen and pelvis on 27 Month1 noted that the gallbladder appeared ‘shrunken’ with at least one gallstone seen. On 28 Month1, Mrs A’s records (set one) were sent to ICU, and these included reference to the cholecystectomy in 2005.
    
    
40. I obtained independent advice from radiologist Dr David Milne. Dr Milne did not identify any departure from accepted practice in relation to the interpretation of the ultrasound and CT reports. On a blind reading of the imaging provided, without the relevant history, Dr Milne identified an abnormal gallbladder. Dr Milne advised that given the difficulties he and his own radiology colleagues encountered in interpreting the images correctly without an accurate history when they undertook a blind reading, the previous history of the cholecystectomy in 2005 is critical to the interpretation of this imaging. Dr Milne considers that the omission of this critical history made accurate interpretation and diagnosis unachievable.
    
    
41. I accept this advice. As noted above at paragraphs 33–37, I consider that the deficiencies in care are the result of multiple staff at Palmerston North Hospital not reviewing Mrs A’s previous history adequately and Health NZ not ensuring that significant details of Mrs A’s history were readily available. I note that Mrs A’s history of cholecystectomy was not available to radiology at the time of the ultrasound and CT scan and was made available to ICU only on 28 Month1. Accordingly, I consider that there was no departure from the accepted standard of care in relation to this aspect of care.

Changes made since events

42. Health NZ told HDC that following on from the recommendations set out in the serious event review, it is working through the implementation of scanning clinical files into the electronic patient clinical portal, which means that staff must check the electronic patient clinical portal as well as the hard-copy file for all patients. Telephone consultations by consultants and registrars are followed up by either completion of the telephone consult forms or a dictated letter for the clinical records.
    
    
43. Health NZ stated that the incident has been discussed with medical teams to ensure that all relevant information is reviewed to make informed decisions.

Recommendations

44. I recommend that Health NZ Te Pae Hauora o Ruahine o Tararua MidCentral:

1. 1. Prepare and present an anonymised case study based on these events for the wider education of medical staff at Palmerston North Hospital. The case study should detail the actions taken and decisions made by staff, the results of these actions/decisions, and the appropriate course that should have been taken. Evidence confirming the content and delivery of the presentation, and to whom it has been presented and when, is to be provided to HDC within six months of the date of this report.
      
      
   2. Provide an update to HDC on the implementation of scanning hard-copy clinical files into the electronic patient clinical portal, within three months of the date of this report.
      
      
   3. Provide confirmation to HDC that coded medical issues are accessible and able to be reviewed by staff, within three months of the date of this report.

45. In the provisional opinion, I recommended that Health NZ Te Pae Hauora o Ruahine o Tararua MidCentral provide an apology to Mrs A and her family for the breach of the Code identified in this report. This apology was received in response to the provisional opinion and has since been provided to Mrs A and her family.

Follow-up actions

46. A copy of this report with details identifying the parties removed, except Palmerston North Hospital, Health NZ Te Pae Hauora o Ruahine o Tararua MidCentral, and the independent advisor on this case, will be sent to Te Tāhū Hauora|Health Quality and Safety Commission and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.