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Complications following knee joint replacement (06HDC09552)

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(06HDC09552, 31 January 2008)

Orthopaedic surgeon ~ Rural hospital ~ District health board ~ Credentialling ~ Knee replacement surgery ~ Morbidly obese patient ~ Artery damage ~ Amputation ~ Documentation ~ Rights 4(1), 4(2)

A 47-year-old woman complained about the adequacy of the services provided by an orthopaedic surgeon in an isolated rural hospital when she had a right total knee replacement. The woman was morbidly obese and the operation technically difficult, and postoperatively the blood flow to her lower leg became severely compromised. The orthopaedic surgeon failed to consult with senior colleagues when faced with an inadequate scan report, and delayed sending her to a larger centre for vascular assessment. A few days later she had an above knee amputation of her right leg as a result of damage to her right popliteal artery that occurred during her surgery.

It was held that the surgeon should have discussed the case with a senior colleague, arranged for back-up support from other specialists, and made the woman aware of the risks related to her weight. The deficiencies in his planning amounted to a failure to provide services with reasonable care and skill, and a breach of Right 4(1). The surgeon did not provide postoperative care of an appropriate standard, by failing to identify the seriousness of the clinical signs in the woman's leg as it became more ischaemic, and by failing to seek advice from the vascular team, also breaching Right 4(1). The surgeon's documentation did not meet professional standards, breaching Right 4(2).

It was held that the DHB took reasonable steps to ensure that the surgeon was inducted into its services and able to provide safe surgical services, and did not breach the Code.

The Commissioner recommended that all DHBs, prior to the appointment of any surgeon to a consultant position (when that surgeon is newly qualified or has not worked at consultant level in New Zealand for at least 12 months), whether on a permanent or locum basis, seek advice from the relevant surgical society or the Royal Australasian College of Surgeons as to the suitability of the proposed appointment, and whether any special support will be needed.

The Commissioner also recommended that the Ministry of Health, all DHBs, and the Royal Australasian College of Surgeons work together to develop and implement a plan to address the issue of credentialling surgical services provided by DHBs (especially in remote areas or smaller centres) and the surgeons who work in such services.