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Complications following gallbladder removal (12HDC00779)

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(12HDC00779, 18 June 2015)

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 day.

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.  


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