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Failure to provide full information; postoperative bleeding and delay in re-operating (12HDC01488)
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(12HDC01488, 10 March
General surgeon ~ District health board ~ Cholecystectomy ~
Postoperative bleeding ~ Death ~ Surgery ~ Informed consent ~ Delay
~ Rights 4(1), 4(4), 6(1)
An elderly man who had significant medical co-morbidities was
reviewed by a general surgeon in the surgical outpatient clinic of
a public hospital.
The surgeon explained to the man that he required a
cholecystectomy (removal of his gallbladder) and a hernia repair
operation, and that because of certain previous surgery, he would
need an open operation, which would be more significant than a
laparoscopic approach. There is no record of any information
regarding possible alternative treatment options having been
provided. At the time, the surgeon was subject to voluntary
restrictions on his surgical practice, which the man was also not
Following the operation the man's condition was initially
unremarkable, but his blood pressure started to drop about an hour
after surgery. Over an hour later, the surgeon arranged an
ultrasound scan, which showed internal bleeding. The surgeon
decided to re-operate to control the bleeding. During surgery, the
wall of the portal vein was damaged, causing further blood loss.
Despite extensive resuscitation efforts, sadly, the man died.
The post-mortem found that the cause of death was hypovolaemic
shock secondary to ongoing blood loss. The source of blood loss was
damage to the left hepatic artery, which appeared to have
been damaged during the initial cholecystectomy, and from damage to
the portal vein, which occurred during the second surgery.
The information about the voluntary restrictions on the
surgeon's practice may have influenced the man's decision to
undergo the surgery at that time and place, and to have had it
performed by that surgeon. By not providing that information, it
was held that the surgeon breached Right 6(1). The surgeon's
decision to proceed with a full cholecystectomy meant he did not
provide services to the man with reasonable care and skill,
breaching Right 4(1).
Following the surgery, the man's prolonged hypotension and
marked drop in haemoglobin was consistent with significant
postoperative bleeding. The delay before re-operating placed him at
risk of harm. Accordingly, the surgeon was found to have breached
Right 4(4). During the second operation, the surgeon made a serious
error when he damaged the portal vein, breaching Right 4(1). The
surgeon was referred to the Director of Proceedings, who decided
not to issue a proceeding.
The DHB was held responsible for the lack of critical thinking
and proactivity of its staff when the man deteriorated
postoperatively. The DHB therefore failed to provide services to
the man in a manner that minimised the risk of harm and,
accordingly, breached Right 4(4).