The Health and Disability Commissioner has criticised the Southern District Health Board and two obstetrician-gynaecologists for the inadequate care of a patient who had surgery to remove an ovarian cyst.
The two senior doctors and the DHB were found to have breached the patient rights' code.
The patient, referred to as Ms A in commissioner Anthony Hill's report, had laparoscopic surgery in March 2013.
The then 51-year-old's bladder was injured in the procedure, which was complicated by the presence of internal adhesions. It was repaired in the operating theatre by a urologist.
After surgery, the first doctor, referred to as Dr C, handed over to a colleague, Dr B.
Ms A's post-operative recovery did not go well, but Dr B did not investigate a possible bowel injury, despite concerns being raised three times by a senior house officer.
When the bowel perforation was diagnosed, Ms A had further surgery.
Mr Hill criticised Dr C for not appreciating the potential for surgical difficulties, given the patient had a history of adhesive disease. However Dr C's only breach of the patient code was in failing to keep clear and accurate clinical and surgical records.
Dr B was found to have breached the code by failing to provide services with reasonable care and skill.
Mr Hill said he was particularly concerned that even when blood culture results were available, Dr B did not review the woman personally or refer her for a surgical review.
Dr B is no longer practising in New Zealand.
Mr Hill recommended that if Dr B returned to New Zealand, the Medical Council should consider a competence review.
Mr Hill said the SDHB had overall responsibility for the deficiencies in Ms A's care.
"SDHB's surgical consent form in use at the time had no space for the purpose of recording risks specific to the patient.
"There were several administrative shortcomings identified in this case.''
Mr Hill told the DHB to ensure clinicians knew the professional requirements for laparoscopic surgery.
Chief medical officer Dr Nigel Millar, in a statement after the report was released yesterday, said the health board accepted the commissioner's findings and "acknowledges the significant impact that the complications from surgery have had on Ms A's life''.
"The DHB aims to provide the best possible care for all of its patients, and has undertaken an in-depth review of the care of Ms A and is implementing the recommendations,'' Dr Millar said.
