09HDC01565 - Health and Disability Commissioner

Table of Contents
Executive Summary ....................................................................................................... 1
Investigation process ...................................................................................................... 2
Information gathered during investigation ..................................................................... 3
Opinion: Introduction................................................................................................... 30
Opinion: Breach — Canterbury District Health Board................................................ 31
Opinion: Dr E ............................................................................................................... 35
Opinion: Dr F ............................................................................................................... 41
Opinion: RN Ms I ........................................................................................................ 42
Opinion: RN Ms J ........................................................................................................ 44
Opinion: RN Ms K ....................................................................................................... 45
Recommendations ........................................................................................................ 47
Follow-up actions......................................................................................................... 48
Appendix 1 — Independent advice — Neurosurgical care ......................................... 49
Appendix 2 — Independent advice — Nursing care ................................................... 56
Appendix 3 — Consent for surgery ............................................................................. 62
Appendix 4 — Postoperative instructions ................................................................... 63
Appendix 5 — Neurosurgery Observation Chart ........................................................ 64
Appendix 6 — Summary of postoperative observations in the SCU .......................... 65
Appendix 7 — Root Cause Analysis and other subsequent action .............................. 66