Source: Health and Disability Commissioner
“On balance I consider it more likely than not that Dr C did not provide Mr A with an explanation of the particular risks of the chest drain procedure, including the risks of damage to another organ, a major bleed, or death.
Ms Cooper added that the doctor also failed to provide services of an appropriate standard – Right 4 – because he did not document the informed consent discussion, clinical decision making or handover notes before finishing his shift. This does not comply with professional or other relevant standards, she said.
The decision centres on the care of the man after surgery. While he was reported as being in a ‘stable and satisfactory position’ after surgery, a chest X-ray a couple of days later found an abnormal accumulation of fluid around his lungs. An attempt to drain the fluid by insertion of the chest drain was unsuccessful and the procedure was abandoned.
The man was sent back to his room for observations but there was no hand over care to the evening team. Later in the evening he collapsed. A scan revealed an injury to his spleen. Unfortunately, the man’s condition deteriorated, and he died three days later.
Ms Cooper also made adverse comment about the doctor for not arranging a follow up X-ray after the unsuccessful procedure. Health NZ had adverse comments relating to having no written policy about when the use of ultrasound guidance should be considered; when to arrange a post-procedure X-ray; and that multiple staff failed to recognise the need for a post-procedure X-ray for the man.
Ms Cooper made a series of recommendations to Health NZ including providing her with progress on its recommendations from its adverse events review, and of the results of an audit to monitor compliance of written consent. She further recommended it develop a policy for chest drain procedures within eight months of her report.
She recommended the doctor apologise to the man’s family and complete HDC’s online learning module on informed consent, and to reflect on deficiencies identified in his care.
Health NZ has made a range of changes since the event which are outlined in the report.
