09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner 156. Dr E considers it unfair to conclude that patients should be explicitly told who is operating in ―most‖ cases, ―when there is an equally logical conclusion that can be drawn by reasonable patients … and a simple step reasonable patients can take if they hold concerns about the identity of the person performing the operation‖. Dr E states that ―the reasonable patient in [Mr A‘s] circumstances would ask if this was an issue of concern‖. Dr E states that he has spoken to surgical and anaesthetic colleagues in New Zealand and Australia, and the majority state their registrars/trainees usually do significant portions of a procedure under supervision without this being specifically discussed with the patient. Dr E therefore considers his practice is ―usual practice or even an acceptable standard of care‖. 157. Dr E also notes the surgery was being performed in a public training hospital where most patients expect that junior doctors and training specialists will be involved in the treatment process. In addition, the consent form clearly stated that the procedure would be performed by an appropriate, not a specific person. As the form was signed by Mr A, Dr E submits it is reasonable to conclude Mr A had read and understood this, or if he did not read it, that it was not a high priority for him. 158. Dr E states that a craniocervical decompression is essentially a high cervical spinal decompression, and in his view, this is ―not a ‗serious‘ operation in the spectrum of neurosurgical procedures‖. 159. Dr E disagrees with Dr Nye‘s advice that there was ―an apparent lack of instruction given to nursing staff‖. Dr E states: ―Instructions were clear on postoperative orders, the patient was also monitored as per PCA protocol and there is an overriding neurosurgical postoperative care protocol in place.‖ 160. Dr E states that while the oxygen saturation probe is a useful tool it has many downfalls. He notes that oxygen saturation readings need to be considered in context with many other factors, and that ―a single reading is essentially meaningless unless accompanied by other clinical concerns‖. 161. Dr E provided further information regarding his supervision of Dr G and Dr F. He states that registrars are instructed about the requirements for patient care and department protocols, both in writing and verbally. He states that Dr G and Dr F were both instructed as to the requirements of his postoperative orders long before they looked after Mr A. The postoperative orders were ―according to‖ Dr E‘s expectations and wishes. 162. Dr E notes he was Mr A‘s initial contact point, and set his treatment plan in action. He states that he ―oversaw and supervised the consent process‖, he was present during the surgical procedure, and he was happy with all stages of the operation. 163. Dr E notes he asked his registrars about Mr A‘s well-being before leaving the hospital, and that it is his usual practice to have any concerns about patients under his supervision directed to him in the first instance, rather than to the consultant on call. Dr E states that he does not consider the consultant in charge is responsible for ―policing the instructions left for junior and nursing staff in the deep hours of the 5 September 2012 28 Names have been removed (except Canterbury DHB and the experts 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.
Opinion 09HDC01565 night and early morning. This is what department and patient protocols are for…‖. Dr E does not consider there was any lack of supervision on his part. 164. Dr E states that ―there is no clear evidence that [Mr A] died of a respiratory event, and […] it could equally have been a (sudden) cardiac or other event‖. Dr E states there is ―definitely no consensus amongst the treating physicians with the [CDHB‘s] RCA opinion of a possible respiratory event‖. Dr F 165. Dr F submits there was no indication that there was any confusion with regard to his postoperative instructions, and as such, he does not consider he should have been expected to clarify his instructions in this specific case. He states that in his experience it is usual practice for postoperative orders to be followed if there is a perceived conflict with the unit‘s protocol, ―that is, where a protocol is expected to be followed, instructions directing staff to follow the specific protocol would normally be prescribed‖. 166. Dr F states that while he accepts the criticism regarding the lack of specific instructions in the postoperative orders, he considers ―it is a reasonable expectation of all medical staff that regular general/vital observations would be performed in all postoperative patients regardless of whether they are on a PCA or have had cranial surgery‖. 167. Dr F also notes his concern regarding the fact that Mr A was found with no oxygen saturation monitor attached and with the monitor switched off. In these circumstances, he states, it is uncertain ―whether specific postoperative instructions would have changed or prevented the outcome as prescribed parameters could never have triggered an alert‖. 168. Dr F notes that he is pleased to hear about the new measures and monitors that have been put in place at CDHB. He considers the ―single most important change, which is indispensable, is the reinforcement of continuous nursing (including handover within the [SCU])‖. RN Ms I 169. RN Ms I‘s legal counsel, Mr P, notes that RN Ms I conducted many of Mr A‘s observations on an hourly basis, and she was observing him regularly. Mr P submits that ―RN [Ms I‘s] failure to record [Mr A‘s] respiratory rate on no more than a few occasions had no influence on the outcome of this tragedy‖ and was not a causative factor. 170. Mr P states that the advice of my nursing expert, Janet Hewson, that respiratory rates should be recorded at all times, is accepted. He submits that any disapproval of RN Ms I in relation to this matter would be mild, given the other observations undertaken by RN Ms I. 29 5 September 2012 Names have been removed (except Canterbury DHB and the experts 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.
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09HDC01565 - Health and Disability Commissioner

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