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Poor management of fluid balance and failure to seek second opinion in patient deteriorating after hepatectomy (01HDC04847)

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(01HDC04847, 7 May 2003)

Surgeon ~ Private hospital ~ Liver surgery ~ Standard of care ~ Informed consent ~ Information about postoperative risks ~ Private/public interface ~ Record-keeping ~ Rights 4(1), 4(2), 7(1)

A woman complained about the care provided to her late husband by a hepatobiliary surgeon and a private hospital.

The complaint was that the surgeon: did not perform a biopsy to establish his diagnosis prior to performing surgery; did not have a consent form signed by the 52-year-old patient prior to operating; did not continue oxygen treatment despite low oxygen saturations; did not investigate and treat appropriately, or facilitate a second opinion, when the patient's condition deteriorated; and did not inform the public hospital of the patient's transfer. In addition, that staff at the private hospital failed to provide appropriate care and treatment in a timely manner.

Independent advice was obtained from a consultant general and upper gastrointestinal surgeon. A preoperative liver biopsy would not have assisted in determining the problem or confirming the correct course of action. Such a biopsy is difficult to perform and, if a malignancy is present, may assist in spreading cancer cells. Oxygen treatment would have made little difference to the patient's overall condition.

The surgeon breached Rights 4(1) and 4(2) in failing to ensure that the patient received care of an appropriate standard postoperatively with regard to:

(1) fluid management, as the patient was inappropriately prescribed sodium-rich saline; (2) the failure to seek a second opinion when the patient's condition was not improving and the family had expressed concern; (3) insufficient efforts to exclude covert sepsis; and (4) failing to ensure that his assessments, decisions and courses of treatment were recorded contemporaneously.

The private hospital did not breach Right 4(1) as: (1) the nursing staff administered the patient's medication appropriately; (2) acted on requests for further medical consultations; and (3) completed the informed consent process appropriately, having ascertained that the patient had no further questions. There was a misunderstanding in relation to the promise of ongoing care and support, which did not amount to a breach of the Code.

The private hospital breached Right 4(2) in failing to ensure an appropriate standard of clinical records, as it was required to do more than encourage compliance with professional standards via newsletters. The hospital failed to ensure there was an accurate record of fluid balance, and that the patient was weighed daily. The Commissioner also commented that the transfer to the public hospital was poorly organised.