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Specialised bowel surgery performed by general surgeon in provincial hospital (07HDC17438)

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(07HDC17438, 21 April 2009)

General surgeon ~ Public hospital ~ District health board ~ Bowel surgery ~ Anterior resection ~ Ileostomy ~ Ulcerative colitis ~ Proctitis ~ Colorectal tumour ~ Scope of practice ~ Vicarious liability ~ Right 4(1)

A 62-year-old woman complained about the care provided by a general surgeon at a public hospital. She was referred to the hospital by her GP for assessment by a general surgeon, because of bowel changes and blood in her bowel motions. The woman had a history of bowel problems and had been diagnosed with ulcerative colitis in the 1970s - information that was included in the referral.

The woman was assessed by the general surgeon, who diagnosed a large pre-cancerous bowel lesion. He performed an anterior bowel resection and anastomosis with a protective ileostomy (an external bag to hold faecal matter). On examination, the resected bowel was found to have active ulcerative colitis.

The woman recovered well and, three months later, the general surgeon reversed the ileostomy. Later that month, however, her condition deteriorated and she was admitted to the public hospital. She developed septic shock and a fistula between her bowel and the ileostomy wound. She went on to have ongoing difficulties with the fistula and significant ulcerative colitis. The remainder of her large bowel was excised by a specialist colorectal surgeon.

One of the key issues in this case is whether it was appropriate for the general surgeon to carry out the type of operation he performed. It was held that the deficiencies in the general surgeon's management amounted to a failure to provide services with reasonable care and skill and, accordingly, he breached Right 4(1).

Although the general surgeon's decision to treat the woman without specialist input demonstrated poor clinical decision-making on his part, the DHB should have had systems in place to support clinicians to refer appropriate cases or seek appropriate input. By this omission, the DHB failed to take all reasonably practicable steps to prevent the general surgeon's breach of the Code, and was held vicariously liable for the breach.