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Care provided to surgical patient who refused blood (11HDC00531)

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(11HDC00531, 30 June 2014)

Public hospital ~ Surgeon ~ Anaesthetist ~ Laparoscopic cholecystectomy ~ Refusal of blood and blood products ~ Rights 4(1), 4(5)

A woman was diagnosed with gallstones and placed on the waiting list for an elective laparoscopic cholecystectomy.  Four days prior to her surgery, the woman attended a pre-admission clinic and confirmed at this time that she did not consent to the use of blood and blood products. The woman's views were recorded in her clinical notes.

The woman was admitted to hospital for surgery. The surgeon and the anaesthetist met with the woman to discuss the operation and obtained her informed consent. When surgery commenced a short time later, the surgeon was unaware of the woman's views in relation to blood and blood products. The anaesthetist was aware of the woman's views, however, the matter was not raised during the surgical "Time Out", when any issues of concern are brought to the attention of the theatre team.    

During the surgery, there were difficulties with access and visibility and it was decided to convert to open surgery. The woman's gallbladder was removed and the operation ended. Following surgery, there were concerns about the woman's condition. Initial measures taken to address these were unsuccessful, and it was thought that the woman was probably bleeding internally. The surgeon instructed that the woman was to be given blood, at which point he was advised of her treatment refusal.

The surgeon determined that further surgery was needed to identify and address the cause of the bleeding. The woman, still partially sedated, confirmed that she would not accept blood. The woman was returned to theatre and no obvious bleeding point was identified. The surgeon determined that the best course of action was to pack the liver bed and close the abdomen, so that the woman could be transferred to a facility better equipped and staffed to manage the situation. Arrangements were made to transfer the woman by helicopter to a larger hospital. By the time the helicopter crew arrived it was decided that transfer was inappropriate. The woman died a short time later.

It was held that the woman's refusal of blood and blood products was information that the anaesthetist and surgeon needed to know prior to surgery and in time for other plans and preparations to be made, should these have been necessary. The arrangements and systems in place at the hospital did not support the timely communication of this information. In addition, the woman's refusal of blood and blood products should have been raised during the surgical "Time Out". Accordingly, the DHB breached Rights 4(1) and 4(5).

The surgeon did not know about the woman's refusal of blood and blood products until her condition began to deteriorate following the first operation. The surgeon did not read the woman's notes sufficiently to obtain this information before commencing her surgery. It was held that the surgeon failed to provide services with reasonable care and skill and, accordingly, breached Right 4(1).

It was held that the anaesthetist failed to take reasonable steps to co-operate with his colleagues to ensure quality and continuity of services, breaching Right 4(5).

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