Health and Disability Commission deputy commissioner Dr Vanessa Caldwell released her decision on Monday concerning the care provided to a woman who presented to Health New Zealand Te Whatu Ora (Health NZ) Southern’s neurosurgery department with neurological symptoms, and the two spinal surgeries she underwent subsequently.
"This case highlights the importance of the consumer’s right to informed consent, and for this to be facilitated in an environment that allows for open and effective communication.
"Ms A had a difficult patient journey. It is understandable that she feels let down by the public hospital. I express my sympathy for the frustration and distress that she experienced."
The operations took place in 2019, and the woman laid a complaint in 2020.
Dr Caldwell said the case involved several issues, including the adequacy of communication, the clinical documentation throughout the patient journey, and the management of the woman’s complaint made directly to the provider.
"The surgeon stated that he met with and discussed the proposed approach with the woman, but she has no recollection of being informed of the change. After the initial surgery, the woman did not improve and her symptoms deteriorated, so further surgery was arranged.
The report said after the second surgery, the woman was prescribed and administered dexamethasone, although the woman said that this was never discussed with her.
"Ms A said that her patient journey experience has left her ‘traumatised, with compromised physical health and uncertainty around future employment’.
"She stated that her overall impression is one of time-pressured staff and extremely poor communication within the treating team and with the patient, which was evident at every point."
Ms A was also very concerned about the standard of documentation, and she found it "inconceivable that surgical and post-surgical notes are not available for the surgeries that she had at the public hospital".
"She stated that with fragmented senior/surgeon staffing, not only is documentation important but actually listening to the patient is vital."
In response, Dr E of HNZ said he could not remember whether he, or any other member of the team, discussed with Ms A her treatment with dexamethasone. He noted that if there were any such discussions, they were not documented.
"In light of the lack of documented discussion, Dr E’s inability to recall whether it was discussed by him or any member of the team, and Ms A’s recollection that the steroid was never discussed with her, I find it more likely than not that Ms A did not receive information about the prescription and administration of steroids and the potential risks, which she needed to make an informed choice," Dr Caldwell said.
Dr Caldwell said she considered these actions reflected "the pressured environment in the service".
"I agree that the documentation is well below the expected standard and, in some aspects, non-existent."
She recommended HNZ Southern apologise to the woman and review neurosurgery service staff training on informed consent and audit its standard of record keeping.
Southern Chief Medical Officer Dr David Gow said Health New Zealand accepted the findings and "we wish to publicly convey our sincere apologies to the patient".
"We are working with the HDC on its recommendations and can confirm several changes have now been implemented, including that neurosurgical operation notes are provided to the Post-Operative Care Unit at the end of surgery and filed on the digital platform Health Connect South for referencing.
"Clear, concise and timely documentation in the patient record is important to promote patient safety, and we acknowledge we fell short of our standards in this case."
