Provision of circumcision

Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Complaint

The Commissioner received a complaint from a mother concerning treatment her son, (the consumer), received from the provider, a general surgeon. The complaint is that:

• In mid-February 1998, the Surgeon performed a circumcision on the consumer. After the circumcision, a dressing was applied to the wound and it fell off almost immediately. A further dressing was applied and became attached to the wound site.
• In the week following surgery, the Surgeon saw the consumer and advised that the dressing was not a problem and it would eventually detach. He recommended long baths twice a day which should loosen the dressing for removal.
• At a follow up visit to the Surgeon in mid-March 1998 the dressing was still attached and covered about half of the underside of the wound site. The Surgeon said he was happy with the way the wound was healing and that if there were any worries the consumer should come back.
• The dressing eventually became putrid smelling and had to be forcibly removed by the complainant. In the weeks that followed the stitches fell out but the complainant was not happy with the look of the consumer's penis as she felt it should have looked smoother. Being unsure of the healing time and not wanting to appear too anxious she did not take the consumer back to see the Surgeon.
• At the beginning of June 1998 the consumer fell over and the scar tissue was pinched by his clothing, causing what looked like an ulcer or an infection. The consumer was taken to his GP and the family was advised that the circumcision did not look as it should and a referral was made to an Urologist.
• The Urologist confirmed that the penis did not look as it should and stated that the consumer "couldn't be left looking like this". The Urologist said that it looked like there had been excessive bleeding into the wound site which would have caused the raised scar tissue.
• The revision was carried out in late June 1998 and the complainant was amazed to see the difference in the wound site and although the penis was swollen it was smooth and even. The stitches were neatly tucked under and there was little blood visible. This contrasted dramatically to the first operation, which was sloppy by comparison. The consumer exclaimed, "I look normal again".
• In mid-July 1998 the complainant wrote to the Surgeon and he promptly responded. The complainant was astounded at the response and she discussed his claim that the problem would resolve itself over time with the Urologist. He thought that the Surgeon was being "wildly optimistic" that this might happen.
• The complainant would have been happy had the Surgeon conceded that the outcome of the surgery was not successful. She appreciates that there is always an element of risk in surgery, and obviously, the consumer's surgery was not successful.

Investigation

The complaint was received by the Commissioner on 19 October 1998 and an investigation was undertaken. Information was obtained from:

• The Complainant / Consumer's mother
• The Provider / General Surgeon
• The Urologist
• The General Practitioner

Relevant clinical records and photographs were obtained and viewed. The Commissioner obtained advice from a General Surgeon.

Outcome Investigation

At the time of the complaint the consumer was six years old. His mother was concerned as the consumer had a tight foreskin which would not retract normally. Although he had not experienced infections, the complainant was worried that her son could experience problems later in life which could require surgery. As the complainant considered surgery when the consumer was an adult to be more traumatic, she consulted her general practitioner for advice.

The GP referred the consumer to the Surgeon for his opinion as to possible surgical correction. The GP's referral letter in early October 1997 to the Surgeon recorded, "Thank you for seeing this five year old boy regarding phimosis and possible partial adherence of the foreskin. He has been attempting to retract the foreskin whilst having a bath however this has not been successful. On examination there is a relatively tight phimosis with foreskin unable to be retracted. Also there appears to be some adherence of the foreskin posteriorly."

The Surgeon suggested applying hydrocortisone ointment to the tip of the penis for a period of time as an alternative to surgery. This method of treatment involved applying the ointment and pulling back the foreskin to gradually stretch this over a period of time. At the first follow-up check-up there appeared to be progress made but at the subsequent check-up the foreskin had tightened up again. During this second period ointment was not applied.

In his report to the GP in late October 1997, the Surgeon advised that his examination confirmed that the consumer had a tight foreskin which would not retract past the tip and was very fibrous. "I would think that this is going to require circumcision. I have suggested Mum might want to try to use some local steroids for a month to see if that helps. Some Hydrocortisone 1% ointment was prescribed. This is to be used on the foreskin and sometimes it works. I will see the child again in a month's time."

In late January 1998 the Surgeon examined the consumer and in a letter to the GP the next day, noted that although the steroids softened the skin, as soon as the treatment ceased "the tight fibrous bit recurred." As there was no permanent improvement the Surgeon recommended circumcision.

In mid-February 1998 the Surgeon performed a circumcision on the consumer at a private hospital.

After the surgery the complainant said there was a dressing applied to the wound site which fell off almost immediately. A replacement dressing was applied at home and part of this dressing became attached to the wound site. In the week following surgery the complainant took the consumer back to the Surgeon because of this complication and he inspected the wound and advised that the attached dressing was not a problem and would eventually detach. He recommended long baths twice a day, which should loosen the dressing for removal.

The scheduled surgery follow-up was in mid-March 1998. At that time the dressing was still attached and covered about half the wound site underneath. The Surgeon indicated to the complainant that he was happy with how the wound was healing but told her to come back if she had any worries. The complainant said the dressing eventually became putrid smelling and she forcibly removed it.

In his response to the complainant in late July 1998, the Surgeon stated that according to his record there was a piece of gauze stuck to the foreskin which he had difficulty removing and this may have been the reason for the scarring. The Surgeon continued, "I am sure the ulceration you described was not related to a fall. The scar tissue would have softened up and corrected spontaneously in time."

At the beginning of June 1998 the consumer fell over and the scar tissue was pinched by his clothing causing what looked like an ulcer or an infection. The consumer was taken by his grandmother to the GP to have it checked. The complainant said the GP informed the consumer's grandmother that the circumcision did not look like it should.

The consumer was referred by the GP to the Urologist. The complainant stated that the Urologist confirmed the circumcision did not look like it should and told her the consumer "couldn't be left looking like this." The complainant informed the Urologist about the adhered bandage and enquired why the penis had healed like it had. The complainant said the Urologist explained that it looked like there had been excessive bleeding into the wound site which would have caused the raised scar tissue. The Urologist explained that there is a risk in all surgery.

The Urologist performed the revision in late June 1998 to address the main problem which was the appearance of the penis. In his operation note the Urologist recorded, "At the circumcision site there was this heaped up collar of redundant skin, tags and scar tissue forming a "ruff" appearance to the penis, the dimensions of the collar being 7-8mm out of the normal and 4-5mms in width circumferentially." The Urologist commented that the ruff had irregular indentations where the stitches were. The operation produced a good cosmetic result.

The complainant was amazed to see the difference in the wound site and that although the penis was swollen it was smooth and even. The stitches were neatly tucked under and there was little blood visible. The complainant said this contrasted dramatically with the earlier operation which was sloppy by comparison. The complainant said, "it really hit home when [my son] exclaimed, in the hospital, after seeing the wound site, 'I look normal again.'"

The complainant said she was much happier with the follow-up care and written information supplied by the Urologist. The private hospital provided a generic surgery aftercare sheet. There were some hand written references specific to circumcision, but she could not recall what, if any, verbal advice was given by the Surgeon. The complainant said her son was extremely distressed after the surgery so she doubts that she would have retained anything that the Surgeon said.

In his letter to the complainant of late July 1998 the Surgeon said that he would have discussed with the complainant the indications prior to the circumcision. The Surgeon said he had been reluctant to circumcise the consumer in the first place and had recommended the use of the steroid cream for a period of time in order to save him an operation. "The object of the exercise was to make sure a phimosis didn't exist and then there would be no dirt collected under the unretractable foreskin, thereby preventing further infections. In all my years of practising surgery, I have never come across an indication for the procedure that was for aesthetic reasons."

The complainant complained in writing to the Surgeon who replied in late July 1998 and stated, "From the accompanying photograph I assume that the complaint was that there was too much redundant foreskin after the operations. It is always my practice to leave more skin than not enough. It is far more difficult to correct a situation when there is not enough skin, than when there is too much. When [the consumer's] genitalia grows, and he will do so in an exponential fashion in a few years time during puberty, the excessive skin will have smoothed over and the aesthetically unacceptable appearance will correct itself." The complainant said she discussed the Surgeon's claim that the consumer's problem would resolve over time with the Urologist who responded that he thought this was 'wildly optimistic'.

The Code of Health and Disability Services Consumers' Rights

RIGHT 4

Right to Services of an Appropriate Standard

Opinion: Breach

In my opinion the Surgeon breached Right 4(2) and Right 4(4) of the Code as follows:

Right 4(2)

My advisor confirmed that a further operation was justified and disagrees with the Surgeon that there is not an aesthetic reason to correct the initial circumcision. "[The GP, the Urologist] and I all agree with [the consumer] (who was embarrassed and recognised something was not normal) and [the complainant] that the result of the first operation was not acceptable. The result was not an acceptable professional standard and revisional surgery was justified."

In my opinion the ruffed appearance of the consumer's penis that resulted from the Surgeon's circumcision did not meet acceptable professional standards and was a breach of Right 4(2) of the Code.

Right 4(4)

The consumer had a non-retractable foreskin and this was the reason he was circumcised. The circumcision produced a result which was not of an acceptable professional standard and for which the consumer had to undergo surgical revision. This revision was necessary as the ruffed appearance of the consumer's penis was not usual and was embarrassing to a developing young boy.

The Surgeon dismissed the need for the revision by insisting the revision was required for aesthetic reasons. However the Surgeon ignored the fact that the unacceptable appearance of the penis was the result of his circumcision and caused embarrassment to the consumer. The Surgeon was under a duty to provide the consumer with a circumcision which resulted in as normal an appearance as possible. By not providing this result, the Surgeon did not optimise the quality of the consumer's life and breached Right 4(4) of the Code.

Actions

I recommend the Surgeon takes the following actions:

• Provides a written apology to the consumer and his mother for breaching the Code. This will be sent to the Commissioner's Office who will forward it to the complainant.
• Reads the Code of Health and Disability Services Consumers' Rights and confirms in writing to the Commissioner that he fully understands his obligations as a provider of a health services.
• Refunds the cost of his fee for the circumcision, and the Urologist's fee. The complainant will send a copy of the Urologist's invoice to the Surgeon.

A copy of this opinion will be sent to the Medical Council of New Zealand and the private hospital involved.

For further information, contact: HDC Communications Section (09) 373 1060.