Importance Of Reading Patient’s Notes Prior To Surgery Highlighted

Deputy Health and Disability Commissioner, Deborah James,
has found a surgeon did not provide services of an
appropriate standard after failing to ensure that he had all
relevant information before performing surgery.

A
woman’s left ureter (a narrow tube that carries urine from
the kidneys to the bladder) was inadvertently injured during
hysterectomy surgery. The surgeon did not read the clinical
notes or the radiology report immediately prior to the
surgery, and did not remember that the woman had a unique
ureter condition, with two ureters draining from her left
kidney into the bladder, rather than the usual
one.

The surgeon accepted that he had caused the
woman’s injury during the surgery and acknowledged that it
is possible that the injury could have been prevented if he
had reviewed the documentation, as was his normal practice.
In her decision, Deborah James determined it was not
reasonable for the surgeon to perform the surgery without
having reviewed the relevant documentation.

“A surgeon
needs to read the notes to the extent necessary to be
satisfied that, as the operating surgeon, they have all of
the information that they need to know.”

As a result
Ms James found the surgeon breached Right 4(1) of the Code
of Health and Disability Services Consumers’ Rights – the
right to have services provided with reasonable care and
skill.

Ms James recommended the surgeon provide a
formal written apology to the woman. She also recommended
the surgeon continue to adopt the changes made since the
incident to ensure clinical notes and preoperative
consultation notes are reviewed prior to surgery being
performed and risk factors are noted on the consent
form.

The Deputy Commissioner acknowledged the effect
this care had on the woman, and suggested the providers
consider coordinating a restorative
meeting.

Editors notes

The full
report of this case can be viewed on HDC’s website – see
HDC’s ‘ Latest
Decisions‘.

Names have been removed from the
report to protect privacy of the individual involved in this
case. We anticipate that the Commissioner will name DHBs and
public hospitals found in breach of the Code unless it would
not be in the public interest or would unfairly compromise
the privacy interests of an individual provider or a
consumer. HDC’s naming policy can be found on our website
here.

HDC
promotes and protects the rights of people using health and
disability services as set out in the Code
of Health and Disability Services Consumers’ Rights (the
Code).

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