Its beggars belief that 36 years after Silvia Cartwright’s cervical cancer inquiry criticised unconsented vaginal examinations performed on anaesthetised women, the issue is still in the headlines.
It seems to crop up every few years.
Concern about such practices played a part in the development of the rights contained in the Health and Disability Code of Rights which encompass situations involving medical students and junior doctors.
Two years ago, we reported a 2018 case before Health and Disability Commissioner Morag McDowell involving a woman who expected to have an intrauterine device inserted by a consultant obstetrician at Dunedin Hospital under general anaesthetic. Instead, the procedure was completed by a medical student and a registrar with other medical students looking on.
She found a code breach — explicit consent for medical students’ involvement was absent and the patient had expressly refused student involvement.
A follow-up audit of gynaecology theatre patients at the hospital over a three-month period did not uncover any further concerns. Ms McDowell was also satisfied with her requirements for further training in consent, capacity and communication and a review of clinical records had been completed.
Last month, Ms McDowell reported on an investigation she initiated into the standard of informed consent at the former Waitemata District Health Board regarding involvement of trainees in providing and observing obstetrics and gynaecology services at North Shore Hospital since January 1, 2018.
She did this because concerns raised in a complaint from a registered nurse at the DHB potentially affected many people and related to wider systems issues at Te Whatu Ora Health NZ.
She found informed consent practices, policies and procedures were significantly inconsistent across the country.
The nurse whistleblower first raised concerns in 2012. Action taken after that brought some initial improvement, but the nurse, who later went on leave and then returned in 2018, found the situation had deteriorated by then. The form had been revised and it made it much harder to tell exactly what a patient had consented to.
Among the many cases the nurse raised concerns about was one where a registrar proposed to involve a house officer in a vaginal examination of a woman under general anaesthesia. Ms McDowell commended the nurse for intervening to stop the examination because there had been no consent gained for it.
It was unclear whether teaching was occurring, but she made the point it would be highly concerning if a vaginal examination was proposed without the patient’s knowledge or consent: ‘‘In such circumstances, explicit consent is clearly required.’’
Ms McDowell said consumers undergoing sensitive examinations should know beforehand who will be involved and what their role will be.
We are not sure why, after all these years, this seems such a difficult concept for all health services to grasp.
Ms McDowell dismissed the argument requirement for specific informed consent would have a chilling effect on doctor training. Most patients would agree to the involvement of medical students. Regardless, all were entitled to information required to make an informed choice.
She has asked Health NZ to report back on progress on its national policy on informed consent at six monthly intervals until the project is complete.
Consistent good practice is long overdue. We understand the whistleblower nurse’s frustration Ms McDowell did not find a breach of the code, choosing instead to make adverse comment about the practices and take an educational approach focusing on the broader, systemic issues,
As the nurse complainant pointed out, there was a long history of her concerns not being adequately addressed. She does not agree there was no harm to patients attributable to poor supervision. Ms McDowell made no findings about individual cases, largely due to evidential concerns.
Another disturbing aspect of this complaint is that the nurse, rather than being lauded by fellow clinicians for standing up for patients’ rights, told Stuff she faced repeated episodes of harassment, was ignored in theatre and told by managers and some colleagues to stop making trouble.
She said she had to retire nine years early because her work became untenable.
Condoning such bullying behaviour discourages speaking out. It must be eliminated.
