Occupations : General Surgeon
Group providers : District Health Board
Rights : 4(1)

Names have been removed (except SDHB and the expert who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

Southern District Health Board

General Surgeon, Dr B

A Report by the Deputy Health and Disability Commissioner

Contents
Executive summary
Complaint and investigation
Information gathered during investigation
Opinion: Introductory comment
Opinion: Southern District Health Board
Opinion: Dr B — breach
Opinion: Dr F — adverse comment
Changes made since events
Recommendations. 20
Follow-up actions. 21
Appendix A: Independent clinical advice to the Commissioner
Appendix B: Independent clinical advice to the Commissioner

Executive summary

This report concerns the care provided by SDHB to a man in 2019, when he presented to an Emergency Department (ED) seven times with abdominal pain.
The man (aged in his fifties at the time of events) had a history of schizophrenia and chronic thought disorder, and lived in a community residential mental health service. Of the seven times he presented to the ED, he was admitted under General Surgery four times, and the working diagnosis was that of constipation secondary to his anti-psychotic medication, clozapine.
At each presentation, the man’s diagnosis remained the same despite little improvement, and in the presence of “red flag” symptoms. Each staff member across the multiple presentations failed to question the diagnosis of clozapine-induced constipation, and further investigations were not undertaken until surgery to examine the abdomen was performed.
During the operation, the man was found to have widespread colon cancer with tumours that had caused a complete bowel obstruction. Sadly, he died of septic shock secondary to metastatic colon cancer.

Findings

The Deputy Commissioner noted that there were numerous missed opportunities by many SDHB clinicians across multiple presentations to investigate the man’s symptoms further and reconsider his diagnosis when he failed to improve. She considered that the cumulative effect of these missed opportunities demonstrated a concerning lack of critical thinking and acceptance of the man’s unimproved condition by SDHB staff, attributable to the DHB as the overall service provider. Accordingly, the Deputy Commissioner found that SDHB breached Right 4(1) of the Code.
The Deputy Commissioner considered that by the time the man was first seen by the clinician responsible for his care, the man had had repeated presentations and an abnormal CT scan, but the general surgeon disregarded the scan and did not initiate further investigation with a colonoscopy or CT colonography. Accordingly, she found that the general surgeon breached Right 4(1) of the Code.
Adverse comment was made about a second general surgeon for the care he provided to the man.

Recommendations

The Deputy Commissioner recommended that SDHB (a) provide HDC with any protocols or procedures that have been developed as a result of the meetings it has since had with mental health care providers from the community, along with evidence of relevant staff training and orientation to these new protocols or procedures; (b) present an anonymised case study of this case to all ED and General Surgery staff at the public hospital, for educational purposes; (c) implement a new policy/procedure (or amend a current policy) about the use of CT scans in the ED; and (d) consider how SDHB can improve continuity of care in situations where a patient is presenting to hospital multiple times.
The Deputy Commissioner recommended that the first general surgeon present an anonymised case study of this case to his colleagues and training doctors within his department, for shared learning.

Complaint and investigation

The Health and Disability Commissioner (HDC) received a complaint from a residential mental health service (the residential service) about the services provided to Mr A by Dr B and Southern District Health Board (SDHB). The following issues were identified for investigation:

Whether Southern District Health Board provided Mr A with an appropriate standard of care in Month1[1] and Month2 2019.
Whether Dr B provided Mr A with an appropriate standard of care in Month1 and Month2 2019.

This report is the opinion of Deputy Commissioner Dr Vanessa Caldwell, and is made in accordance with the power delegated to her by the Commissioner.
The parties directly involved in the investigation were:

Complainant/CEO of the residential service

SDHB Provider

Dr B Provider/general surgeon

Further information was received from:

Dr C Consultant general surgeon

Dr D Consultant general surgeon

Dr F Consultant general surgeon

Dr E Consultant general surgeon

Also mentioned in the report:

Dr G Consultant general surgeon

Dr I ED registrar

Dr J Colorectal surgeon

Independent expert advice was obtained from general surgeon Dr Gerrie Snyman (Appendix A) and emergency medicine specialist Dr Vanessa Thornton (Appendix B).

Information gathered during investigation

Background

Mr A (aged in his fifties at the time of events) had a history of schizophrenia and chronic thought disorder, and had lived in a community residential mental health service since 2014.
Between 12 Month1 and 24 Month2, Mr A presented to the ED at the public hospital seven times with abdominal pain. Of these times, he was admitted under General Surgery four times, and the working diagnosis was that of constipation secondary to his anti-psychotic medication, clozapine.[2]
This report concerns the care provided to Mr A at SDHB, in particular the care provided during his surgical admissions.

First ED presentation — 12 Month1

At 9.36pm on 12 Month1, Mr A was taken to the ED by residential service staff, as he had been complaining of pain, nausea, and that something “was not right” in his stomach.
Mr A was reviewed by ED registrar Dr I, who obtained Mr A’s history (with assistance from a support worker from the residential service) as recurrent sharp abdominal pain and a three-day history of constipation and nausea, but no vomiting. Vital signs and a full blood count were taken, with no abnormalities noted other than a C-reactive protein (CRP) of 16[3] (marking inflammation) and a fast heart rate of 113 beats per minute (bpm).[4] At this presentation, it was recorded that Mr A expressed fear that he might have bowel cancer.
A rectal examination found no masses or blood, and although an X-ray showed a distended (swollen) transverse colon,[5] this was noted to be similar to previous X-ray imaging undertaken in 2013. Mr A was examined by an ED consultant, who noted his abdomen to be soft and non-tender.
The impression was that of constipation secondary to clozapine, and Mr A was discharged home with laxative medication and paracetamol for pain relief.

Second ED presentation and first surgical admission — 13 Month1

ED care

Mr A re-presented to ED the following afternoon (13 Month1) around 3.00pm, accompanied by a care worker, as he was not eating, his bowels had still not opened, and he had ongoing discomfort. The ED notes state that Mr A denied rectal blood, weight loss, vomiting, fever, or discomfort with urinating, but it was noted that he was a poor historian.[6]
Mr A’s abdomen was noted to be tender all over and “distended ++”, and his blood test revealed a slightly elevated CRP level of 22. The impression was that of severe constipation secondary to clozapine, and Mr A was admitted to the General Surgery ward under consultant general surgeon Dr G.

Surgical care

During this admission, Mr A was provided with laxative medications as per SDHB’s “Porirua Protocol”, which provides guidance to staff on the management of constipation in patients taking clozapine.
By 15 Month1, Mr A had passed three large bowel motions. He was also reporting no pain, and his observations were stable, so he was discharged with laxative medication to take in the community, and advice to seek medical attention if he could not pass bowel motions again.

Third ED presentation — 18 Month1

Mr A was taken to ED on 18 Month1 by residential service staff because of further abdominal pain, but it was noted that he had opened his bowels that morning. He was seen again by Dr I. Blood tests were unremarkable (other than a slight increase in his CRP level to 28), and an X-ray of his abdomen showed a reduced distended transverse colon compared to the X-ray taken on 12 Month1.
Residential service staff relayed to the ED staff that Mr A had been more aggressive and threatening in the last few weeks, which was abnormal. In view of Mr A’s worsening aggression, ED staff decided to refer him to the Emergency Psychiatric Service (EPS), where he was assessed and admitted to the acute psychiatric ward. Residential service staff told HDC that they were not informed of this admission, and were advised that Mr A had been discharged to EPS only when they contacted the hospital to see how Mr A was doing the following morning.
During his stay in the acute psychiatric ward, Mr A declined blood and urine tests, but laxative medication given was effective at relieving his constipation. By 25 Month1, Mr A’s mood had settled, and he reported his bowels being regular with no abdominal pain or bloating, and so he was discharged from EPS.

Fourth ED presentation — 1 Month2

On 1 Month2, Mr A again presented to the ED with abdominal pain, and was noted to be distressed. Blood tests were unremarkable, other than an increased CRP level of 36. X-rays of Mr A’s chest and abdomen showed no free gas or obstructions.
Mr A’s pain was considered to be a result of the recent laxative use (from his 13 Month1 admission), and he was discharged home shortly after having presented, with the advice to stop taking the laxatives.

Fifth ED presentation and second surgical admission — 3 Month2

ED care

Mr A was taken to the ED via ambulance on 3 Month2 with abdominal pain, and again was seen by Dr I. Dr I documented:

“Patient known to me from previous presentations. Very poor historian. Right sided abdominal pain. Not sure about duration. ? for 3–4 days. Not sure when last opened his bowels. Denied nausea, vomiting, [discomfort when urinating].”

It was also noted that despite the advice from his last presentation to stop taking the laxative sachets, Mr A was still taking these. A rectal examination revealed no abnormalities, and a full blood count was unremarkable aside from a further increase in CRP level to 43 and a mild rise of lipase.[7] X-rays of Mr A’s chest and abdomen were similar to his previous images.
Mr A was reviewed by the ED Senior Medical Officer, who queried the possibility of a large bowel obstruction, and Mr A was admitted to the General Surgery ward that evening under consultant general surgeon Dr C.

Surgical care

Dr C’s General Surgery admission note documented Mr A’s multiple previous admissions to ED with similar symptoms, and noted that Mr A had an increased body mass index (and weighed over 100kg), and had had “possible unquantified weight loss recently”. A plan was made to keep Mr A in hospital for observation and pain relief, and to repeat blood tests and review him in the morning.
On 4 Month2, Mr A was not in his ward for the morning ward round, but repeat bloods showed that his lipase levels were stable and that there were no other concerning signs. Dr C told HDC that he recalls seeing Mr A in the corridors during his evening ward round, and Mr A relayed that his pain was settling. The nursing notes document that Mr A’s vital signs remained normal, and he was eating and drinking and given pain relief regularly. However, his bowels had not yet opened.
By 5 Month2, Mr A was passing gas well, had eaten breakfast, and had minimal abdominal pain with stable observations. Dr C reviewed Mr A on the morning ward round and palpated his abdomen, and noted that no mass or tenderness was felt.
Dr C told HDC that the investigations undertaken during this admission (rectal examination, bloods, and X-rays) indicated that Mr A’s clinical picture was consistent with clozapine-associated constipation, and did not clearly indicate another diagnosis (such as a mechanical large bowel obstruction) at that time. As such, no further investigations were initiated.
Mr A was asked to remain in hospital until he had passed a bowel motion, at which point he could be discharged. He remained in hospital overnight, and whilst he did not pass a bowel motion, he was noted as feeling “well” on 6 Month2, and was discharged back to the residential service.

Sixth ED presentation and third surgical admission — 13 Month2

On the morning of 13 Month2, Mr A reported to residential service staff that he was not feeling well, and a GP appointment was made for the following day. However, by that afternoon, Mr A was noted by staff to be in “obvious distress”, as he was vomiting, crying, and begging for help. He was unable to get off his bed as he was too weak, and he appeared very pale and gaunt. It was also noted that he had lost a “noticeable” amount of weight recently.
An ambulance was called and Mr A was taken to hospital, with a “very tight and distended” abdomen.

ED care

Mr A was reviewed in the ED at approximately 5pm, where the history of abdominal pain associated with vomiting “brown stool” was described. On examination, Mr A’s abdomen was distended with high-pitched bowel sounds.
Blood tests showed an elevated CRP at 117 with a rise in urea and creatinine (indicating impaired renal function). Mr A’s haemoglobin levels were on the low side at 142g/L (normal levels for males are between 140 g/L to 180 g/L), indicating a slightly low red blood cell count.
Intravenous fluids were initiated. An X-ray of the abdomen showed “dilated loops” of the small bowel (indicating a possible obstruction). A computerised tomography[8] (CT) scan of the abdomen was arranged, and Mr A was admitted to the General Surgery ward under the care of consultant general surgeon Dr B, with the impression of a potential small bowel obstruction.
The CT scan was reported that evening and showed a “transition point” (a point where the bowel changes from normal to abnormal, potentially indicating an obstruction) on the left side of the transverse colon, with no obvious cause. A plan was made for Dr B to review Mr A in the morning.

Surgical care

At 8.30am on 14 Month2, Dr B reviewed Mr A on the morning round. Dr B considered Mr A’s CT scan and noted that Mr A had been vomiting (which had not been the case on previous admissions) and he had a distended, soft and non-tender abdomen, and was dehydrated. However, by that morning, Mr A had had four loose bowel motions. Dr B’s impression was that of Mr A’s previous diagnoses, ie, clozapine-induced constipation that had resolved with laxatives.
The plan made was to undertake a bowel and fluid chart and repeat blood tests to check Mr A’s renal function.
Mr A was next reviewed by Dr B on the morning ward round on 15 Month2. Dr B noted that Mr A was “feeling okay today. Nil pain today in abdomen” and that he looked comfortable. Dr B told HDC that his plan was to request a contrast CT scan[9] to see whether the contrast dye passed the transverse colon, but when he saw Mr A in the ward, he had a soft, non-tender abdomen and had started to pass a large amount of bowel motions. It was also noted that Mr A’s bloods showed that his kidney function had improved during his admission. Dr B told HDC that this clinical picture fitted very well with a pseudo obstruction,[10] and so he decided to discharge Mr A.
On the afternoon of 15 Month2, Mr A was documented to be agitated about his impending discharge from hospital, and was “refusing to go home”. As such, he was kept overnight until he became more settled. Mr A was discharged home on 16 Month2 with a primary diagnosis of clozapine-related constipation and a pseudo obstruction, and a plan for him to follow up with his GP, continue laxative medication, and have repeat blood tests to check his kidney function.
Dr B told HDC that he has had the opportunity to reflect on this admission with the benefit of hindsight. He stated:

“I accept that there was an abnormality on the limited CT scan and I should have planned to urgently assess this further. As [Mr A] had opened his bowels, it would have been appropriate to do this investigation as an inpatient or as an urgent outpatient colonoscopy. I acknowledge the error of not referring him for an urgent outpatient colonoscopy.

In addition, [Mr A] had a slight anaemia [low red blood cell count] and hypoalbuminemia [a deficit of the protein albumin in the blood] ... I accept that these blood samples, in combination with the finding on the CT scan warranted further investigation with colonoscopy.”

Dr J, a colleague of Dr B, provided further comment about Mr A’s presentation on this occasion. Dr J stated that Mr A’s situation (and in particular the results of his CT scan) is not infrequently seen with a pseudo obstruction. He noted that it was documented that by the following day Mr A had had a dramatic improvement — he was moving his bowels and his abdominal distention had resolved. Dr J stated that while this can occur with a mechanical obstruction, this type of dramatic resolution is more common with a pseudo obstruction. He told HDC: “[T]he clinical picture did seem consistent with the previous (in retrospect incorrect) diagnosis of a functional colonic disorder [the clozapine-induced constipation].”

Seventh ED presentation and fourth surgical admission — 24 Month2

On the morning of 24 Month2, residential service staff requested an ambulance for Mr A as again he was complaining of increased pain in his abdomen. On arrival, the ambulance officers felt that Mr A’s abdomen was significantly distended and firm to touch. At this time, Mr A told the officers that his pain had reduced, but his caregiver noted that Mr A often understated his pain.
Mr A was transferred to the ED, and arrived at approximately 7.42am.

ED care

On examination in the ED, Mr A’s pain was described as being “5/10” across his abdomen, and his bowel sounds were noted to be “very very very scant”. He had a high heart rate at 115 beats per minute and a CRP level of 65.
The impression was that of an obstruction, potentially related to clozapine, and Mr A was referred to General Surgery under the care of consultant general surgeon Dr F.

Surgical care — 24 Month2

On admission, Mr A was reviewed and examined by a surgical registrar, who documented a plan to continue laxative therapy and encourage eating and drinking as tolerated and document this on a food and stool chart, and to repeat blood tests the following day.
Contact was made with Mr A’s primary caregiver, who provided background information relating to Mr A’s changes in behaviour (decreased activity and mobilisation, and less general interest) and also reported that he had had a loss of appetite with some notable, but unquantifiable, weight loss. It was documented that Mr A’s caregiver thought that something else was going on rather than just constipation.
Mr A was noted to have slept overnight, without any complaints of pain or nausea.

25 Month2

Mr A was reviewed by Dr F and his team on the morning of 25 Month2. Dr F considered Mr A’s three previous admissions with similar symptoms, and it was noted that Mr A’s bowels had moved the previous night, and that he felt that his symptoms were not as severe as during his last admission. Dr F told HDC that Mr A’s radiology was reviewed at this time, comparing the abdominal X-rays from the current admission with those from previous admissions, and he noted that there appeared to be little change. He also reviewed the CT scan from Mr A’s previous admission, and his assessment was that there was a pseudo obstruction.
Dr F documented a plan to start Mr A on a laxative regimen and to liaise with his psychiatrist regarding the possibility of alternative therapy for his mental health.
Dr F stated that the confounding issue in this case was Mr A’s continued prescription of clozapine. Dr F stated:

“Clearly, if his obstructive symptoms had continued despite cessation of this medication, then there would have been a strong indication for further investigation of the colon for an alternative diagnosis.”

On behalf of Dr F, his team made contact with Dr B, to enquire whether he would like to resume care of Mr A considering that he had been the consultant from Mr A’s previous admission, or whether he had any management advice that could be useful. Dr F told HDC that Dr B did not wish to transfer Mr A to his team, and Dr B stated his view that Mr A did not have a surgical problem, and that medical treatment of his constipation should suffice.
In response to the provisional opinion, Dr B clarified that the reason he could not take over care of Mr A was that he was leaving for a holiday the following day. He noted that he did not do any clinical examination of Mr A on 25 Month2 when he was admitted under Dr F, and that he did not review any charts or blood samples of Mr A at that point.
The night nurse documented that Mr A was asleep during each overnight check.

26 Month2

On the morning of 26 Month2, Mr A was reviewed by consultant general surgeon Dr E. Dr E was charged with reviewing Dr F’s patients at this time, as Dr F was working at a private hospital all day.
Dr E noted that Mr A had slept well overnight, was passing gas, and had had no increased distress despite his distended abdomen. Dr E reviewed the notes from the previous day and saw that Mr A’s imaging had been reviewed and that the plan was to continue a laxative regimen as per the Porirua Protocol unless new changes developed.
That afternoon, Dr F’s team contacted Mr A’s psychiatric service to ask whether the clozapine could be discontinued, but they were advised against this given Mr A’s unstable schizophrenic psychosis.

27 Month2

At approximately 5am on 27 Month2, Mr A woke up unsettled. He was noted to be unable to explain exactly how he felt, but he stated that he was “not right”, and vomited a small amount of brown faecal-looking liquid. The night nurse (who had reviewed Mr A during his last hospital admission) documented that Mr A appeared pale, with a rigid and distended abdomen. The nurse also noted that Mr A appeared to have lost weight around his face and limbs.
That afternoon, Mr A became more distressed, uncomfortable, and agitated, with increasing pain. Blood tests showed an increased CRP to 149, a high lactate of 9.6 (which can indicate sepsis or shock), and increased potassium and sodium levels.
Owing to increasing concern about Mr A’s clinical deterioration and his worsening test results, the decision was made to undertake surgery to examine the abdomen[11] for a presumed large bowel obstruction. During the operation, Mr A was found to have widespread colon cancer with tumours that had caused a complete bowel obstruction.
Mr A was transferred to the intensive care unit (ICU) after the surgery, but he made very little progress postoperatively. Given the operative finding of extensive metastases, and the poor prognosis, palliative care was commenced.

Subsequent events

Sadly, Mr A died on the evening of 1 Month3. His cause of death was noted as septic shock, secondary to metastatic colon cancer.

Further information

The CEO of the residential service told HDC that Mr A had no family to advocate on his behalf, and that the residential service as an organisation and individual staff had to intervene to ensure that he was able to access services when he was experiencing severe pain, and strongly advocated for appropriate treatment of this. She stated:

“I have to question if [Mr A] would have received a different service and experienced a better outcome if he was not a mental health consumer experiencing a chronic mental illness.”

SDHB

SDHB stated that this case has highlighted the importance of ensuring patient-centred care and the need to communicate appropriately with the primary caregivers for patients in vulnerable situations. It told HDC:

“With the additional challenges [Mr A] faced and lack of family available to support and advocate for him, there should have been more proactive engagement with his primary carer and/or the clinical manager of [the residential service]. The primary carers could have provided valuable additional information and were clearly taking an interest in his clinical progress.”

SDHB also told HDC that this case highlights the detrimental effect that results when there is lack of continuity of care, such as when a patient is readmitted to different inpatient areas on multiple occasions or cared for by different staff. The DHB noted that often this is dictated by bed availability at the time.

Dr B

Dr B told HDC:

“I have reflected long and hard on my role in this matter and the care that I provided. The lesson I have learned from managing this patient is that a suspicion of a change on a CT scan should be further assessed … The fact that [Mr A] had a poor medical history and had presented on two earlier occasions with little improvement in his symptoms suggested that an urgent further investigation with colonoscopy was appropriate.”

However, Dr B stated that Mr A’s diagnosis was not an easy one to make at the time, and noted that Mr A presented to four experienced consultants during the span of two months.

Responses to provisional opinion

SDHB was provided with the opportunity to comment on the provisional opinion. It stated that with minor exceptions, SDHB considers that the provisional opinion is fair and accurate, and that the proposed recommendations are appropriate. It does, however, believe that the context of the care is important and that the proposal to refer SDHB to the Director of Proceedings is disproportionate to the failings, particularly given the steps taken by SDHB since the event.
SDHB stated:

“SDHB extends its sincere condolences to those who knew [Mr A], including staff at [the residential service]. As you know, SDHB and [Dr B] have since reflected on the care provided to [Mr A] and consider that it should have been of a higher standard. SDHB has also taken steps to ensure a situation like this does not occur again.”

SDHB told HDC that it is also in the process of making changes to its process, including changes that go further than the recommendations made in the provisional opinion, for which I commend SDHB. These changes have been added below, in the “changes made since events” section of the report.
Dr G stated that it is unfortunate that Dr B has been “singled out” in the report, and that there were a number of failings shared by a number of people, which were exacerbated by the clinical factors as outlined in the report. In particular, Dr G noted that Dr B was practising in an environment that was different from the environment in his home country, and Dr G recalls Dr B saying that in his home country he would have arranged an inpatient colonoscopy (which he probably would have done himself) — but he had found it almost impossible to get an inpatient colonoscopy approved in the public hospital.
I acknowledge the stated access issues for this service, but consider that this should not be a reason for not making an appropriate referral. In not making the referral, Dr B himself made the decision for the service not to be available for Mr A.
Dr F acknowledged the adverse comment made in respect of the care he provided to Mr A, and stated:

“This case has caused me to reflect on the problem of cognitive bias in clinical medicine, and I have taken away the valuable lesson of always considering the patient in front of you with an open mind and a willingness to consider all options.”

In mitigation, Dr F re-stated that he was the fourth consultant surgeon caring for this patient, and his admission findings appeared identical to those observed by his colleagues on Mr A’s three previous admissions.
Dr B was provided with the opportunity to comment on sections of the provisional opinion relevant to him. He stated that while he largely agreed with the report, he asked that the decision to find him in breach of Mr A’s rights be reconsidered.
Dr B has submitted that at the time of the events he was new to New Zealand, and the traditions of care were quite different to what he was used to. In particular, in the normal course of events he would have arranged for an inpatient colonoscopy, which is always available in his home country, but this was not the case in the public hospital. He stated: “The imposition of a breach leaves me with the impression of being singled out for what was an issue involving many consultants and systemic issues.”

Opinion: Introductory comment

First, I wish to acknowledge that Mr A’s diagnosis was not straightforward. My independent general surgery advisor, Dr Gerrie Snyman, noted that “it is unlikely that the diagnosis of metastatic cancer could have been made much earlier than at the time of surgery”. He stated that from the documentation, there was no specific reason to suspect the possibility of metastatic disease. I also acknowledge that this was further complicated by Mr A’s use of clozapine, a medication known to cause constipation.
However, the issue here is not the failure to diagnose cancer earlier, but the failure to investigate Mr A’s symptoms fully, and to consider an alternative diagnosis after multiple presentations with no improvement. This case highlights the importance of critically assessing patients when they present to hospital on multiple occasions with the same symptoms within a relatively short period of time.

Opinion: Southern District Health Board

Care provided to Mr A — breach

Mr A had a history of schizophrenia and chronic thought disorder, and took the anti-psychotic medication clozapine to manage this. Between 12 Month1 and 24 Month2, he presented to SDHB’s ED seven times with abdominal pain. On four of these occasions, he was admitted as an inpatient under the General Surgery team. At each presentation, the same investigations were undertaken — abdominal X-rays, rectal examinations, and blood tests — and the same diagnosis of clozapine-induced constipation was made. Blood tests showed that Mr A’s CRP levels were increasing steadily, but the abdominal X-rays and rectal examinations were unremarkable.
Mr A was under the care of a different consultant at each of his four General Surgery admissions (Drs Dr G, Dr C, Dr B, and Dr F), but the overall care provided was the same (laxatives and pain relief). A CT scan was not undertaken until Mr A’s sixth presentation, and, despite the scan showing the possibility of an obstruction, further investigations were not undertaken and the diagnosis did not change at any time.
It was not until the fourth day of Mr A’s seventh presentation (and fourth surgical admission), when Mr A’s condition began to deteriorate, that further investigation by way of a laparotomy was undertaken. At this time, Mr A was found to have widespread colon cancer with tumours that had caused a complete bowel obstruction. Mr A died on the evening of 1 Month3 as a result of sepsis secondary to the cancer.
My independent emergency medicine specialist, Dr Vanessa Thornton, advised that abdominal pain continues to be a diagnostic challenge and a common presentation for emergency clinicians. She stated that in many cases, the differential diagnosis is wide, ranging from benign to life-threatening conditions. Often the associated symptoms lack specificity, and atypical presentations of common diseases are frequent, further complicating matters. Regarding the care provided to Mr A at the public hospital’s ED, Dr Thornton advised that each of the seven presentations were met with appropriate ED assessments, and referrals to the surgical inpatient team were made when warranted.
I accept that when looking at each of the ED visits in isolation, the care provided to Mr A was appropriate, and he was referred to General Surgery when necessary.
My expert general surgery advisor, Dr Gerrie Snyman, noted that a functional bowel problem is a diagnosis by exclusion, and the initial diagnosis of clozapine-induced constipation fitted with this. However, he stated that with each subsequent admission, doubt about this diagnosis should have arisen, especially as there had been no investigations to clear the bowel. His concern is that the possibility of an alternative diagnosis was not considered. Dr Synman advised:

“I, and a good many of my colleagues, would consider new onset abdominal pain with associated change in bowel habit that does not settle on adequate treatment to be a definite red flag for further investigation.”

This widespread failure to think critically about other causes for Mr A’s symptoms was then compounded by Mr A’s abnormal CT scan, taken on his sixth admission, which raised the possibility of an obstruction. Despite not undertaking any further investigations into this possibility, SDHB staff continued to believe that the clinical presentation fitted with a diagnosis of pseudo obstruction, and did not amend the working diagnosis. Dr Snyman advised:

“By [Mr A’s] third admission to general surgery it should have been a duty of care to ensure that pathology was excluded. This happened with the performance of a CT scan. When the CT was abnormal, this should have been followed up with further investigations, not discarded.”

Dr Snyman advised that noting the continued relatively benign abdominal findings on subsequent ward rounds, these clinical findings were not enough to discard the CT findings in the context of Mr A’s longitudinal history. Dr Snyman considers that a diagnostic colonoscopy/CT colonography should have been undertaken as the next step (as either an in-patient or out-patient), and that the omission to do so was a “major deviation” from the accepted standard of care, which I accept.
Mr A presented again to SDHB after the CT scan had been taken, on 24 Month2. Dr Snyman stated that at this admission, the possibility and plan to investigate the bowel to exclude pathology should have been front and centre in Mr A’s care plan. However, despite the abnormal CT scan, no further investigations were undertaken until Mr A’s condition deteriorated on the fourth day of this admission.
Overall, Dr Snyman advised:

“[Mr A] presented and represented multiple times to SDHB with the same complaint. During the first few presentations it would have been reasonable to treat him without further investigations. During subsequent presentations and admissions, the responsibility to ensure appropriate diagnosis and treatment should have increased significantly. This did not happen. Instead every admission steadfastly repeated the previous admission plan, despite the evidence that the treatment was not working, hence the representation. No further tests were undertaken to ensure the appropriate diagnosis has been made.”

I agree with this advice. Unresolved and new symptoms in the context of repeated presentations to hospital should have triggered a reconsideration of the working medication-related diagnosis, and broader investigations into the cause of the abdominal symptoms, with greater urgency.
While there is individual accountability for the decisions made (discussed below), I consider that the system let Mr A down. The issue at the centre of this case is that Mr A re-presented to SDHB on multiple occasions, and whilst the initial diagnosis of clozapine-related constipation was reasonable, each time Mr A presented subsequently with the same unresolved issue, that working diagnosis became less probable, and should have triggered further investigation and other alternative diagnoses by any of the many doctors who saw Mr A.

Conclusion

As set out above, Mr A presented to SDHB on multiple occasions during Month1 and Month2. At each presentation, Mr A’s diagnosis remained the same despite little improvement, and in the presence of “red flag” symptoms. Each staff member across these multiple presentations failed to question the diagnosis of clozapine-induced constipation, and further investigations were not undertaken until the laparotomy on 27 Month2.
I consider that these failures were compounded by anchoring bias, a lack of continuity of care, and the failure to engage with the residential service to elicit further details of Mr A’s symptoms and history, in light of him being a poor historian. Mr A was a vulnerable mental health patient who had no family to advocate on his behalf, and he was let down immensely by the DHB and a number of its staff.
There were numerous missed opportunities by many SDHB clinicians across multiple presentations to investigate Mr A’s symptoms further, and re-think his diagnosis when he failed to improve. The cumulative effect of these missed opportunities demonstrates a concerning lack of critical thinking and acceptance of Mr A’s unimproved condition by SDHB staff, attributable to the DHB as the overall service provider. Accordingly, I find that SDHB breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code).[12]
I acknowledge that Mr A’s illness was metastatic when diagnosed on 27 Month2, and that an earlier diagnosis may not have influenced the ultimate outcome. However, I note my expert’s comments that an earlier diagnosis of colon cancer could have opened up opportunities for palliative care that could have led to Mr A having a significantly different end to his life.

Consideration of an earlier CT scan in ED — other comment

My independent emergency medicine specialist, Dr Thornton, considered that there was the potential for Mr A to have undergone an earlier CT scan. Noting that it was Mr A’s sixth presentation to the ED when the abdominal CT was performed, she advised:

“A CT can assist in the diagnosis of undifferentiated abdominal pain and ED can initiate an abdominal CT. CT is the study of choice in the evaluation of undifferentiated abdominal pain. Approximately two-thirds of patients presenting to the ED with acute abdominal pain have a disease that can be diagnosed by CT … With the frequency of presentations an earlier CT may have assisted with the diagnostic dilemma with [Mr A].”

Dr Thornton did, however, note that the diagnosis of constipation made in the early presentations would not require a CT, and that consideration of the use of clozapine as a probable cause of constipation “was not unreasonable”.
I am mindful of the apparent reluctance to perform a CT scan in the ED until Mr A had presented with the same symptoms six times in little over a month. Having a lower threshold to undertake a CT scan in the ED may have assisted in an earlier diagnosis of Mr A’s symptoms. I consider that this is a potential area for improvement by SDHB, and I will make a recommendation to this effect.

Opinion: Dr B — breach

Dr B was the consultant general surgeon overseeing Mr A’s care from 13 Month2 to 16 Month2. By the time Dr B saw Mr A, he had been seen in the ED at the public hospital six times previously, and it was his third admission under General Surgery.
At this time, a CT scan of Mr A’s abdomen had been performed and showed a transition point, potentially indicating an obstruction, with no obvious cause. Dr B reviewed Mr A on the morning ward round on 14 Month2. Dr B looked at the CT scan and noted that Mr A had been vomiting, and that he had a distended, soft and non-tender abdomen, and was dehydrated. By that morning, Mr A had had four loose bowel motions.
Dr B told HDC that his plan was to arrange a contrast scan to see whether the dye passed the transverse colon, but by the following morning, Mr A had a soft, non-tender abdomen and had started to pass a large amount of bowel motions. As such, Dr B considered that Mr A’s clinical picture fitted very well with a pseudo obstruction, and he decided to discharge Mr A. No further investigations were undertaken, and the diagnosis remained that of Mr A’s previous admissions, ie, clozapine-induced constipation.
My independent general surgery advisor, Dr Gerrie Snyman, stated that by Mr A’s third admission to General Surgery, pathology should have been excluded, and this happened with the performance of a CT scan. However, when the CT was reported as abnormal, this should have been followed up with further investigations, not discarded.
Dr Snyman considers that the relatively benign clinical findings during the ward rounds in this admission were not enough to discard the CT findings in the context of Mr A’s longitudinal history. Dr Snyman stated: “I personally, and I suspect a good proportion of my colleagues, would have completed an in-patient colonoscopy or CT colonography during this admission.” He advised that if Mr A did not receive a same-admission colonoscopy or CT colonography, he should at least have received an urgent out-patient colonoscopy. Neither occurred in this case.
Dr Snyman considers the disregard of Mr A’s CT scan and the lack of considering alternative causes to constitute a “major deviation” from the expected standard of care, which I accept.
I note Dr J’s statement that Mr A’s situation (and in particular the results of his CT scan) is not infrequently seen with a pseudo obstruction. I also note Dr B’s comment that Mr A’s diagnosis was not an easy one to make at the time, and that Mr A presented to four experienced consultants during the span of two months before the diagnosis was made.
In response to the provisional opinion, Dr B submitted that at the time of the events, he was new to New Zealand and the traditions of care were quite different to what he was used to. In particular, in the normal course of events he would have arranged for an inpatient colonoscopy, which is always available in his home country, but this was not the case in the public hospital. He stated: “The imposition of a breach leaves me with the impression of being singled out for what was an issue involving many consultants and systemic issues.”
I have considered Dr B’s submissions. My expert advisor considers that further investigation should have been done during Mr A’s 13 Month2 admission either by way of a same-admission colonoscopy or CT colonography, or at least by an urgent out-patient colonoscopy. Neither occurred in this case. While SDHB has acknowledged (outside of this case) that there were access issues for colonoscopy services, considerable improvements have been carried out in partnership with the Ministry of Health, and access to colonoscopy services will continue to be monitored. Nevertheless, the accepted standard of care was to have arranged a colonoscopy, and even if Dr B was not sure whether it would be approved, it was his responsibility to take steps to request it. In not making the referral, Dr B made the decision himself not to make the service available to Mr A. It is necessary to single out Dr B in this instance, as he was the clinician responsible for Mr A’s 13 Month2 admission and, by this time, Mr A had had an abnormal CT scan that warranted further investigation, which makes the omission to arrange a colonoscopy significant.
As noted previously, the issue in this case is not the delay in diagnosing Mr A’s condition, but the failure to reconsider Mr A’s diagnosis in the context of his repeated presentations and abnormal CT scan, and the failure to investigate this abnormality further by way of a colonoscopy or CT colonography. I find that for the above reasons, Dr B did not provide Mr A with services with reasonable care and skill, in breach of Right 4(1) of the Code. I note that Dr B has reflected on the care he provided, and accepts that further investigation was warranted.

Opinion: Dr F — adverse comment

On Mr A’s seventh presentation to the public hospital’s ED on 24 Month2, he was admitted for the fourth time to the General Surgery team under the care of consultant general surgeon Dr F. During this admission, Dr F reviewed the CT scan from Mr A’s previous admission, and his assessment was that there was a pseudo obstruction.
Contact was also made with Dr B to enquire whether he wished to resume care of Mr A or whether he had any management advice that could be useful. Dr F told HDC that Dr B did not wish to have Mr A transferred to his team, and Dr B’s view was that Mr A did not have a surgical problem, and medical treatment of his constipation should suffice.
Mr A was continued on his laxative therapy until 27 Month2, when he deteriorated and was taken for surgery. At this time, his diagnosis of metastatic cancer was made, and, sadly, he died shortly afterwards.
My independent general surgery advisor, Dr Snyman, noted that at the time Mr A was reviewed by Dr F, it was Mr A’s fourth admission under General Surgery and his seventh admission to hospital overall with persistent symptoms. Dr Snyman feels strongly that as soon as Mr A was readmitted on this occasion, the previous CT scan result should have taken centre stage in formulating a care plan. Dr Snyman stated:

“The review of the CT scan should have raised a red flag and the possibility of pathology. In my opinion the care plan should have included a repeat CT scan or colonoscopy or both.”

Dr Snyman considers that the three days on which Mr A was in hospital with no documented plan to clarify or investigate the persistent symptoms and abnormal CT shows a “trend towards deviation from standard of care”. I accept this advice, and consider that in light of Mr A’s previous abnormal CT scan, and his continuing unresolved symptoms, Dr F should have arranged for further investigations before Mr A’s deterioration on 27 Month2.
I do wish to acknowledge that Dr F’s team made contact with Dr B, for advice on management and to enquire whether he would like to resume care of Mr A. This was an attempt to keep Mr A’s care continuous, and I commend Dr F for this.

Changes made since events

SDHB

SDHB told HDC that over recent months there have been a number of meetings with mental health care providers from the community (including the residential service), led by the Director of Nursing Surgical. These have been aimed specifically at developing protocols and procedures to improve communication and environmental aspects, so that SDHB can better meet the needs of consumers with mental health needs who develop acute surgical or medical issues.
SDHB stated that there were a number of learnings from the meetings, which included:

Recognising the vulnerability of patients with chronic mental health conditions when they enter the hospital for physical health care;
How to value the input from, and work more collaboratively with, NGO providers;
Identifying that it did not have a sound communication pathway;
For this type of vulnerable patient who is presenting repeatedly to ED, to create an alert and plan to send the patient to a “home ward” for subsequent admissions for continuity of care (noting that Mr A was admitted to different surgical wards on each admission); and
Ensuring that the NGO providers know who to go to with concerns about care or management plans and issues with hospital process.

At the time of meeting with the residential service, SDHB provided residential service staff with a formal apology for the care provided to Mr A.
In response to the provisional opinion, SDHB informed HDC of other changes that currently it is in the process of making.
To further improve communication between the residential service and medical staff at SDHB, SDHB has provided the residential service with contact details for the charge nurse managers for all wards, as well as the directors of nursing. This is so that the residential service can contact these people with any concerns, and they can share valuable information they may have about patients. These SDHB staff members are then able to help advocate for the patients, and can facilitate meetings between the residential service and medical staff if needed.
In addition, SDHB has considered the use of alerts for vulnerable patients who attend ED frequently. The alerts would be linked to an electronic ED care plan for the person, provide the contact details for the relevant NGO provider, and identify the patient’s “home” ward where the person would be placed (except in situations where the patient needed specialist care). SDHB told HDC that this would enhance continuity of care and communication between SDHB and mental health care providers. SDHB expects to implement this project by mid-2022.
SDHB has also begun work on the “Yellow Envelope” initiative for patients who also have mental health needs. This is a communication tool currently used in the clinical handover of residents of aged-care facilities to and from hospital. The tool involves the completion of a checklist that includes key information about the patient, to assist with the evolution and management of the patient.
SDHB told HDC that it recognises that the way in which acute surgical patients have been assessed, admitted, worked up, operated on, and discharged from the General Surgery service has remained largely unchanged for a number of years, and that there is room for improvement in this area. To address this, SDHB has introduced the “General Surgery Acute Service Project 2021” (the “Acute Surgical Project”). The aim of the Acute Surgical Project is to deliver a service to patients who need acute general surgical care that is timely, of a high quality, equitable, and good value for money. In addition, SDHB aims to optimise the working conditions, teaching, learning, and satisfaction of staff who deliver the care.
SDHB stated that it is in the process of accurately defining the current state of the acute General Surgery service, defining the issue/s with the service, identifying data, developing solutions to achieve the ideal or optimal state, and identifying the enablers essential to success and the measures to demonstrate whether outcomes are achieved. SDHB noted that it has also sought input on the Acute Surgical Project from relevant stakeholders, including patients/whānau, GPs, rural hospital doctors, ED staff, surgical house officers/ registrars/consultants, surgical nurses, theatre staff and anaesthetists, as well as line managers and the Executive Leadership Team as necessary.
Since these events, improvements have also been made to SDHB’s inpatient colonoscopy services. In particular, the DHB has streamlined referral acceptance processes, increased clinical capacity, and reviewed acute bowel cancer presentations. The Ministry of Health told HDC that SDHB now delivers a service that meets all of the standards outlined by the National Bowel Screening Programme.

Dr B

Dr B currently works as the head of a public colorectal unit in his home country. He told HDC that the lesson he has learnt from the management of Mr A is that suspicion of a change on a CT scan should be assessed further, even if the clinical problem has resolved and the patient looks much better the next day. Dr B stated that this is something he will change in his future practice.

Recommendations

I acknowledge that SDHB has already provided residential service staff with a formal apology for the care provided to Mr A. In addition, I recommend that SDHB:
Provide HDC with any protocols or procedures that have been developed as a result of the meetings outlined in paragraph 124, along with evidence of relevant staff training and orientation to these new protocols or procedures. The first update on these developments is to be provided to HDC within three months of the date of this report. Three-monthly updates are then to be provided to HDC until the completion of this recommendation.
Present an anonymised case study of this case to all ED and General Surgery staff at the public hospital, for educational purposes. The main learnings from the presentation should include the importance of:

Continuity of care;
Having a low threshold for obtaining a CT scan in the ED when a patient presents with abdominal pain;
Thinking critically when a patient presents to hospital with the same unresolved symptoms multiple times in a short period of time;
Recognising and addressing anchoring bias; and
Communication with a patient’s primary caregiver when the patient is unable to communicate effectively.

Evidence that this has been done is to be provided to HDC within three months of the date of this report.

Implement a new policy/procedure (or amend a current policy) about the use of CT scans in the ED. This policy/procedure should provide guidance to ED staff on having a lower threshold for requesting a CT scan as a diagnostic tool when a patient presents to the ED multiple times with abdominal pain. Evidence that this has been done is to be provided to HDC within three months of the date of this report.
Consider how SDHB can improve continuity of care in situations where a patient is presenting to hospital multiple times. The outcome of the consideration, and any changes made as a result, are to be sent to HDC within three months of the date of this report.
I recommend that Dr B present an anonymised case study of this case to his colleagues and training doctors within his department, for shared learning. Evidence that this has been done is to be provided to HDC within three months of the date of this report.
I recommend that the Medical Council of New Zealand consider whether this matter should be brought to the attention of Dr B’s Medical Association, as currently Dr B is working in his home country.

Follow-up actions

SDHB will be referred to the Director of Proceedings in accordance with section 45(2)(f) of the Health and Disability Commissioner Act 1994 for the purpose of deciding whether any proceedings should be taken.
A copy of this report with details identifying the parties removed, except the experts who advised on this case and SDHB, will be sent to the Medical Council of New Zealand, and it will be advised of Dr B’s name.
A copy of this report with details identifying the parties removed, except SDHB and the experts who advised on this case, will be sent to the residential service, the Director of Mental Health (the Ministry of Health), the Mental Health and Wellbeing Commission, the Cancer Control Agency, and the Health Quality & Safety Commission, and placed on the Health and Disability Commissioner website, hdc.org.nz, for educational purposes.

Appendix A: Independent clinical advice to the Commissioner

The following expert advice was obtained from general surgeon Dr Gerrie Snyman:

“REF: 19HDC01214

Complaint: Southern District Health Board/[Mr A] (dec)

I have been asked by the HDC to provide an opinion to the Commissioner on case number 19HDC01214.

I have read and agree to follow the Commissioner’s Guidelines for Independent Advisors.

My name is Christoffel Gerhardus Snyman. I qualified as a Fellow of the Australasian College of Surgeons (FRACS) in 2003. I am a full time consultant general surgeon in a public hospital.

I do not have a personal or professional conflict in this case.

Expert advice requested

Please review the documentation and advise whether you consider the care provided to [Mr A] at SDHB was reasonable in the circumstances, and why.

Please note that we have already sought expert emergency specialist advice on the care provided to [Mr A] at [the public hospital’s] emergency department.

In particular, please comment on:

The reasonableness of the overall general surgical management of [Mr A] at SDHB.
The adequacy of the care provided to [Mr A] by each individual general surgeon ([Dr C], [Dr G], [Dr F], [Dr D], [Dr B] and [Dr E]).
Whether a CT scan or other imaging should have been considered earlier.
Whether it was reasonable to attribute [Mr A’s] bowel obstruction episodes to a functional disturbance given the CT scan result of 13 Month2, and whether further follow up of this result should have occurred.
The adequacy of the pain relief provided to [Mr A] (both as an inpatient and on discharge).
Whether the multiple presentations of [Mr A] to SDHB should have triggered any further investigations or course of action that was not done in this case.
The adequacy of the communication with staff from [the residential service].
The adequacy of the relevant SDHB policies and procedures in place at the time of these events.
Any other matters in this case that you consider warrant comment/amount to a departure from accepted standard of care.

For each question, please advise:

What is the standard of care/accepted practice?
If there has been a departure from standard of care or accepted practice, how significant a departure do you consider this to be?
How would it be viewed by your peers?
Recommendations for improvement that may help to prevent a similar occurrence in future.

Documents provided

Letter of complaint dated 4 July 2019
Southern District Health Board’s response dated 16 August 2019 and attachments.
Clinical records from Southern District Health Board covering the period [Month1] and [Month2].
Response and clinical records from [the ambulance service]
Southern District Health Board’s response dated 18 May 2020

Additional Resource

Referral Criteria for Direct Access Outpatient Colonoscopy or Computed Tomography Colonography. Ministry of Health Guidelines.
NZFormulary.org — Clozapine
https://bpac.org.nz/2017/clozapine.aspx (reference Porirua protocol)

Summary

[Mr A], aged [in his fifties] at the time of these events, had a history of Schizophrenia and chronic thought disorder, and lived in a contracted community residential mental health service.

Between 12 [Month1] and 24 [Month2], [Mr A] presented to the … emergency department seven times with abdominal pain and BNO — bowels not opening. Of these times, he was admitted under general surgery four times, and the working diagnosis was that of constipation secondary to his anti-psychotic medication.

On 14 [Month2], during his third admission under the general surgery team, a CT scan of [Mr A’s] abdomen showed a distended bowel and a possible obstruction. The general surgeon’s plan was to do an acute contrast colon however when he saw [Mr A] in the ward, he had a soft non-distended and non-tender bowel, and had started to pass a large amount of bowel motions. The general surgeon subsequently discharged him with pseudo obstruction.

On 27 [Month2] an urgent laparotomy was performed after a CT scan of [Mr A’s] abdomen showed evidence of an obstruction, and [Mr A] was becoming increasingly unwell. The laparotomy found an obstructive tumour, and significant colorectal metastasis throughout the abdomen.

Summary of Questions.

The reasonableness of the overall general surgical management of [Mr A] at SDHB.

Major Deviation from Standard of Care

The adequacy of the care provided to [Mr A] by each individual general surgeon ([Dr C], [Dr G], [Dr F], [Dr D], [Dr B] and [Dr E]).

[Dr B]: Major Deviation from Standard of Care

[Dr F]: Trending towards a Deviation from Standard of Care

Whether a CT scan or other imaging should have been considered earlier.