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Complications following gallbladder removal (12HDC00779)
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(12HDC00779, 18 June
General surgeon ~ Anaesthetist ~ District health board ~
Cholecystectomy ~ Informed consent ~ Post-operative care ~
Documentation ~ Rights 4(1), 4(2), 6(2), 7(1)
A 74-year-old man presented to the Emergency Department (ED) at
a hospital due to a sudden onset of right-sided back pain. He had a
number of co-morbidities at the time. Following a renal ultrasound
that showed multiple gallstones, ED clinicians discharged him and
referred him to the Surgical Outpatients Clinic for a possible
cholecystectomy (surgical removal of the gallbladder).
A general surgeon reviewed the man and recommended he undergo an
open cholecystectomy and incisional hernia repair. The man had a
preoperative anaesthetic assessment, and the anaesthetist
recommended that the man's planned surgery be delayed six months
because of issues with his medication. The man subsequently
underwent treatment at the hospital for kidney stones. He had a
pre-surgical assessment at the hospital, but later presented at the
ED with left-sided back pain.
The man presented at the hospital for the planned surgery. The
surgeon discussed the man's recent medical history with him in the
morning and made a considered decision to proceed with surgery.
However, she did not record any discussion with the man.
The man underwent surgery, which was longer and more difficult
than expected. Postoperatively he was transferred to the Intensive
Care Unit. During the next 24 hours the man's condition
deteriorated. He was in pain and had low urine output, raised
creatinine levels, ECG (electrocardiogram) changes, and an
increasingly distended abdomen. The man was treated by a number of
doctors. At about midnight, a second general surgeon performed an
exploratory laparotomy and repair of a jejunal perforation.
However, the man continued to deteriorate and, during the afternoon
was transferred to another hospital, where he died the following
The general surgeon who performed the man's first surgery did
not record any discussion she had with him about whether the
gallstone-related pain he was experiencing, if any, was significant
enough for him to undergo surgery in light of alternative
management options, or the risks of surgery that were specific to
him, including his increased risk of death. In the absence of any
documented evidence that these issues were discussed, the
Commissioner found that the surgeon failed to provide the man with
information that a reasonable consumer in his position would have
needed to make an informed choice about treatment in breach of
Right 6(2) and that the surgeon did not obtain the man's informed
consent for surgery, in breach of Right 7(1). The surgeon
demonstrated a lack of reasonable care and skill in deciding to
perform surgery on the man, and her approach to the man's condition
postoperatively was insufficiently cautionary. In these respects,
the surgeon breached Right 4(1). In addition, the surgeon's
documentation fell below professional standards and, accordingly,
she breached Right 4(2).
It was also held that there was a lack of discernible
leadership, coordination and critical thinking in the clinical team
treating the man postoperatively, and a lack of support offered by
senior doctors to junior staff. This demonstrated a service level
failure by the district health board (DHB) to provide services with
reasonable care and skill, and was a breach of Right 4(1).
Furthermore, there was a pattern of suboptimal documentation by
clinical staff treating the man postoperatively. The DHB failed to
ensure that staff met expected standards of documentation, and
breached Right 4(2).
Adverse comment was made about the DHB's preoperative process
and consent to treatment processes. Comment was made on the DHB's
Enhanced Recovery After Surgery (ERAS) protocol, and on the DHB's
communication with the man's family.
Adverse comment was also made about the postoperative care
provided to the man by the surgeon who performed the second
surgery, and an anaesthetist.