09HDC01565 - Health and Disability Commissioner

Health and Disability Commissioner
It follows that there was a degree of inadequacy of the post operative observations and
monitoring.
As stated the failure to monitor the patient‘s respiratory rate following surgery may
have led to an unawareness of deterioration in respiratory function.
I would further comment as follows:
a. Post operative monitoring instructions should have been for quarter hourly
neurological observations (Glasgow Coma Scale) and pulse rate, respiration rate
and blood pressure for the first hour after surgery and then half hourly for two
hours, and hourly for the remainder of the first 24 hour post operative period.
The decision to reduce observations to two hourly at 11.00 pm on the day of
surgery was considered inappropriate.
b. Responsibility to give post operative observation instructions including changes
requiring action lies with the surgeons involved in treatment, namely [Dr F] and
the supervising Surgeon [Dr E].
c. Continuous pulse oximetry would be desirable for the first 24 hours following
surgery.
Telemetry would not be regarded as a standard practice, and I do not consider matters
of colloid administration, patient position, mobilising and straining relevant to the
issues at hand.
2. Please comment on the changes that Canterbury District Health Board has made
since these events. In your view, have the concerns arising from [Mr A’s] case been
adequately addressed?
Reference has been to protocol changes made by the Canterbury District Health Board
subsequent to the incident under consideration, and the issues raised have been
adequately addressed.
3. Please comment generally on the standard of care provided to [Mr A] by [Dr E]
from [the time of his diagnosis in 2008 to the day of [Mr A’s] death].
As stated, I consider that the treating Surgeon [Dr E] provided the patient with
adequate information regarding his condition and treatment options and that informed
consent was valid.
I consider the treating Neurosurgeon had sufficient experience to [manage] the
patient‘s condition.
The adequacy of care provided by the treating Neurosurgeon could be questioned on
the basis of post operative instructions to nursing staff.
The treating Surgeon‘s documentation was considered satisfactory.
5 September 2012 52
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.