Source: Health and Disability Commissioner
The importance of assessing and managing a patient’s nutritional status adequately, and recognising the risk of nutritional deficiency was highlighted in a decision published by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
In her decision Dr Caldwell found a surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code), for failing to provide care to a woman following gastric sleeve (bariatric) surgery with reasonable care and skill.
The woman underwent gastric sleeve surgery privately with a bariatric and gastric surgeon in October 2018. Approximately two weeks after the surgery, the woman went to the Emergency Department (ED) with vomiting and nausea, the cause of which was uncertain and unable to be diagnosed immediately. The initial impression was of some twisting of the lower end of her stomach remnant, but appendicitis was also suspected.
The woman’s appendix was removed and her symptoms resolved for a short period of time and she was discharged. However, she was then re-admitted to hospital on two subsequent occasions with ongoing symptoms of nausea and vomiting. The woman was found to have developed a moderate post-gastric-sleeve stenosis – a thickening of the muscle between the stomach and small intestine, causing food to be obstructed. Following treatment, her symptoms of nausea and vomiting resolved, but she was re-admitted to hospital in January 2019, when she began to experience progressive tingling and pain in her feet, legs, and hands, and was unable to move properly.
Because of the woman’s prolonged nutritional deficiency relating to previous obesity, poor nutritional intake, the anatomical and functional changes caused by the surgery, and the lack of supplementation and macronutrients following the surgery, she developed polyneuropathy (simultaneous malfunction of nerves throughout the body) and required rehabilitation to assist her recovery.
Dr Caldwell considered, “the surgeon did not assess and manage the woman’s nutritional status adequately, and did not provide the necessary multivitamin supplementation”.
“Over a period of more than 40 days from her first hospital admission until the third balloon dilatation was performed and her symptoms finally resolved, the woman was troubled by nausea and vomiting, and had limited nutritional intake, but no multivitamin supplementation was provided to her.
“The woman had repeated hospital stays during which she received no multivitamins. While multiple staff members were involved in the woman’s care, ultimate responsibility for overseeing the woman’s recovery following her surgery rests with the surgeon, and in my view, she overlooked her nutritional assessment and requirements during her hospital stays,” says Dr Caldwell.
Dr Caldwell made adverse comments about the district health board (DHB), now Te Whatu Ora, as staff did not recognise the risk of nutritional deficiency, and did not identify and act on the woman’s need for nutritional support and multivitamins. She also made adverse comments about both the surgeon’s and the DHB’s clinical documentation.
Dr Caldwell recommended the surgeon provide a written apology to the woman for the deficiencies in her care, and continue to adopt the changes made to her practice by providing patients who have had bariatric surgery with a three-week course of thiamine, advising patients to start taking multivitamins as soon as they are able to tolerate these after surgery, seeking the advice of a dietitian for patients who have had issues with eating or drinking for more than five days, and giving patients who are admitted to hospital an intra-muscular dose of multivitamins.
Dr Caldwell also recommended that Te Whatu Ora provide a written apology to the woman, provide training to all clinical staff who were involved in the woman’s care, on the importance of assessing a patient’s nutritional status, and review the quality of its clinical documentation to ensure its staff accurately record the advice given to patients at discharge.
Names have been removed from the report to protect privacy of the individual involved in this case. We anticipate that the Commissioner will name DHBs and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. HDC’s naming policy can be found on our website here. https://www.hdc.org.nz/decisions/naming-policy/
