09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner INFORMED CONSENT On the information available I am satisfied that informed consent was obtained from an adult male competent patient prior to surgery being consistent with the principles stated in the Code of Health and Disability Services Consumers‘ Rights document. I am of the view that proper and adequate information was conveyed to the patient being a reasonable person capable of making a reasonably informed decision regarding the undergoing of the recommended procedure. I believe that ―material‖ risks of the proposed procedure were stated and that the patient‘s temperament, health, personality and level of understanding were considered in the consenting process which I believe was valid. There is a possibility of a fatal complication occurring following any neurosurgical procedure of the magnitude suggested to the patient in this instance, however in consideration of an acceptable low risk provision of detailed information regarding such a possibility is not, in my opinion, essential to the consenting process and could in an anxious and apprehensive patient lead to a decision not to undergo surgery and to the patient‘s detriment. SURGICAL PROCEDURE The documentation indicates that an appropriate procedure was performed in a technically sound manner by a senior neurosurgical registrar trainee under direct supervision of the responsible surgeon. The standard of treatment in this regard could not be questioned and this is supported by the absence of any post mortem finding indicating a direct surgical complication such as haemorrhage, brain swelling, infarction or direct injury to neural structures. POST OPERATIVE CARE — ANALGESIA/OBSERVATIONS The use of patient controlled analgesia is an accepted technique for patients undergoing surgical treatment as employed in this case. The opiate Morphine was administered in a standard dose and the total dose administered was well within accepted levels, and in the hours prior to the patient‘s death use was limited, … [comments deleted as not relevant to the advice sought]. Notwithstanding the above comments monitoring of patients using PCA is essential in detection of adverse reactions or dose excess with consequences particularly respiratory depression and altered conscious state. It is currently recommended that observation of both respiration and arousal level be used in combination for purposes of monitoring, and in this instance it is apparent that the former was not the subject of specific observation and recording and this may have contributed to an unawareness of deterioration in respiratory function albeit unrelated to the PCA technique. With respect to the recording of patient arousal levels I would express surprise that with the protocol used, the sedation score recording of level 4 (normally sleepy, easy to rouse) did not require specific response, but the lower recording of 3 (somnolent, 5 September 2012 50 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 difficult to arouse) did indicate a response requirement by nursing staff. However in this instance if the correct protocol recommendations were adhered to at the time of assessment the nursing staff actions were consistent with the protocol requirements. 43 PULSE OXIMETRY OXYGEN SATURATION Pulse oximetry oxygen saturation recording post surgery is considered appropriate following surgery of the type undergone and analgesic technique employed, however no specific instruction was identified in regard to action to be taken if falling levels were recorded. In this instance, the nursing notes record a fall in saturation to 94% at 5.00am from a level of 98% previously observed, and in a patient administered intranasal oxygen this fall is significant of an impairment of respiratory function. It appears that the significance of this fall in saturation was not appreciated. It is noteworthy that subsequent to the incident under consideration a Root Cause Analysis has resulted in a change in protocols used at the treating Hospital. [Section deleted as not relevant to advice sought] RESPIRATORY FAILURE POST SURGERY FOR CHIARI MALFORMATION There is literature evidence (reports) of respiratory failure due to central control disturbance of respiration following surgery for CM with adverse and fatal outcome unassociated with any direct surgical complication. In response to specific matters raised in your request for advice I offer the following comments. 1. Please comment generally on the standard of care provided to [Mr A] at [the] Hospital [on Days 1-3]. The preceding comments have addressed a number of aspects regarding the standard of care provided to the deceased at [the] Hospital from [Day 1-3]. I would further state that I consider the decision to provide [Mr A‘s] post operative care in the Special Care Unit was appropriate, and consistent with current standards of management of patients following neurosurgical procedures as undergone in this instance. Comment has been made with respect to an apparent lack of instruction given to nursing staff regarding the post operative care of the patient and I refer particularly to observations of respiration, and response to altered levels of oxygen saturation as indicated by pulse oximetry. 43 See footnote 22. 51 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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Canterbury District Health Board Co
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09HDC01565 - Health and Disability Commissioner

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