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Unsuccessful laparoscopic sterilisation surgery (07HDC03504)

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(07HDC03504, 26 February 2008)

Medical officer ~ Obstetrician and gynaecologist ~ Tubal ligation ~ Credentialling ~ Incident reporting ~ Peer review ~ Supervision ~ Recruitment ~ Medical Council processes ~ Documentation ~ Informed consent ~ Rights 4(1), 4(2), 6(1), 7(1)

This inquiry examined why laparoscopic sterilisation surgery (tubal ligation) performed by medical officer Dr Roman Hasil at Wanganui Hospital in 2005-06 was unsuccessful for eight of 32 women. Six of those women became pregnant and were confronted with difficult decisions. Most decided to have a termination.

On one level, what happened is simple. The medical officer did not place clips correctly on the Fallopian tubes of eight women. But why such a basic mistake was made - resulting in a sterilisation failure rate of 25%, compared with an accepted failure rate of 0.2% - is more complex.

The medical officer was an experienced obstetrician and gynaecologist who had been head of an obstetrics and gynaecology (O&G) department in Slovakia for six years. But from 1996 to 2005, he had a chequered work and medical registration history in Australia.

In August 2005, he commenced work as a medical officer in the O&G department of Whanganui DHB, which for many years had been understaffed and unable to recruit specialists. His background should have come to light during the process of his employment and registration in New Zealand. It did not, owing to inadequate reference checking and credentialling.

The medical officer was granted registration by the Medical Council within a provisional general scope of practice. Under the terms of his registration, he was required to be supervised by the head of the O&G department. The medical officer and his supervisor worked in a grossly understaffed department, with a demanding and unsustainable 1 in 2 on-call component.

From the outset concerns were raised about the medical officer. They initially related to his competence. Then health issues emerged. He was reported to be smelling of alcohol while on duty on several occasions. The concerns about his competence did not abate, and further patient and staff complaints were received. During 2006, four of the medical officer's patients returned to the DHB pregnant following sterilisation surgery.

It was held that the medical officer did not provide services of an appropriate standard in a number of respects. In particular, he did not perform laparoscopic sterilisation surgery on two patients with reasonable care and skill - his record-keeping was inadequate, and his informed consent process in relation to another patient was substandard. He breached Rights 4(1) and 4(2) of the Code in relation to two patients, and Rights 6(1) and 7(1) in relation to another.

His supervisor was aware of concerns about the medical officer, but did not consider that he was unsafe. The supervisor was overworked, but he followed up the concerns with the medical officer and remained satisfied that he was performing to an acceptable standard. In hindsight, that was an error of judgement, but given what he knew at the time, he took reasonable actions to supervise the medical officer.

It was held that the DHB did not fulfil its duty of care. The DHB breached Right 4(1) by its lack of care in employing the medical officer, by failing to have a system in place to monitor his practice effectively, and by failing to respond to his competence and health concerns in a timely and effective manner.

Good policies and procedures are to no avail if they are not followed in practice. It is unacceptable that the sterilisation failures were not exposed by any of the DHB's systems for quality assurance, such as incident reporting, audit, peer review and supervision. Despite the raft of quality assurance policies and procedures at the DHB, they were not followed, and chance played a large part in exposing the cluster of failed sterilisations.

This report highlights the need for hospitals to have effective processes in place to identify and respond to concerns about a clinician's practice. Staff need to be aware of the processes, and adequately trained and supported in their implementation. Management and clinical leadership are critical. It is tempting to cut corners when faced with endemic workforce shortages. But a lack of care in appointing staff, and failure to identify problems and act decisively, results in unnecessary harm to all involved - to patients, to doctors, and to public confidence in a local hospital.

It is the Medical Council's responsibility to ensure that doctors registered in New Zealand are competent and fit to practise. This includes responsibility for registering new international medical graduates and for reviewing reports from its regulatory supervisors during the provisional registration period. However, the Council's responsibility does not detract from a DHB's obligation to properly credential and monitor the performance of an employed doctor.

Given New Zealand's increasing dependence on newly registered international medical graduates to staff hospitals (especially in smaller centres) it is essential that supervision is not "watered down". Effective supervision is critical for safe health care. The Medical Council has a key role to play in training and supporting regulatory supervisors, and employing DHBs must appropriately support and resource clinical supervision.

Public hospitals face major pressures related to workforce and training, distribution of skills and skill mix, and financial resources. These are particularly acute in smaller centres. Isolation is the "kiss of death" for a clinician, a department, and a DHB. Regional and national service planning, and increased co-ordination and collaboration across DHBs, is essential to maintain safe, good quality services in the face of these pressures.