In September 2020 the patient, a male in his 60s, underwent a minimally invasive surgery for a cancerous tumour in the lower left lobe of his lung. Instead, the upper left lobe was removed erroneously.
This was confirmed by an examination of the removed lobe which showed no traces of cancer, while CT scans revealed the remainder of the lung had lost its blood supply.
In the report, the doctor (referred to as Dr B) claimed their error in judgement was a result of the lung rotating during surgery, citing a medical phenomenon called lung torsion.
The accident in the first procedure meant the man required further surgery to remove his entire left lung and remaining tumour.
However, the medical mishap was not made clear to the man or his family until after the second surgery was completed.
The report said there were also documented concerns from the associate charge nurse, who said the patient had "no clear understanding" as to what had occurred during the first surgery.
The man's family said he has since lost income and quality of life as a result of a painful recovery period, and he has now developed inoperable cancer in his remaining right lung.
The doctor has apologised unreservedly to the man and his family.
Dr Richard Bunton, head of the Department of Cardiothoracic Surgery at Dunedin Hospital, provided independent clinical advice to the commissioner. Bunton advised the technique and care leading up to the first surgery was of an acceptable standard but deteriorated soon after.
"'It is a little difficult to understand why 'alarm bells' did not ring when after dividing the inferior pulmonary vein (to the lower lobe), which (Dr B) clearly did, he went on to divide the upper lobe," Bunton said in the report.
"This vein is situated in the anterior-superior position of the hilum and clearly not related to the lower lobe."
"(Dr B) was clearly disorientated at the time of surgery. Thoracoscopic surgery is done within a confined space with the use of various telescopes and optics. However, there is no resigning from the fact that the result was due to a major error in judgement and removal of the wrong lobe in such a patient would be considered to be a severe departure from accepted practice."
Bunton described Dr B's operation notes as "a little brief" and lacking in detail, but advised that while Dr B's documentation was "barely adequate", it was still within the accepted standard of care.
"This case is the only case I could find in the literature where a wrong lobe had been removed. It is important to reflect however that such cases may not be reported in the literature," he said.
"As intimated previously it is hard to imagine how this could occur in the hands of an experienced surgeon."
The Health and Disability Commissioner found Dr B in breach of Right 4(1), Right 6(2), and Right 7(1) of the code.
Right 4(1): Every consumer has the right to have services provided with reasonable care and skill.
Right 6(2): 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): Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise.
