09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner Further information obtained from Dr Nye on 21 July 2010 ―I respond to your communication of the 14 July 2010, and your query regarding my statement that the decision to move to two hourly monitoring at 11.00 pm the night following surgery was inappropriate. This opinion reflects a personal view regarding patients who have undergone posterior cranial fossa surgery in that I believe that the observation rate should not be less than hourly in the first 24 hours post surgery. I have noted that the change to two hourly observations was not inconsistent with the CDHB‘s ―Neurosurgical Post Operative Guidelines‖, and I would indicate that the recommendations contained in these guidelines are consistent with policies currently in use in Neurosurgical Units in both private and teaching hospital situations in Melbourne. I would indicate that there is nothing specific in relation to the treatment of the deceased which prompted my comment, which reflects an entirely personal view. I trust the above comments are of assistance to you in this matter, please do not hesitate to contact the writer should any further statement be required.‖ Further information obtained from Dr Nye on 22 November 2010 ― 1. I consider it reasonable for [Dr E] to state that if surgery was successful [Mr A] would be able to return to [work]. This implies a complete recovery from surgery, and the condition for which it was recommended. The only other overriding matter might relate to [employment] protocols regarding the medical and surgical history of [employees], and I have no knowledge regarding any protocols that might apply. 2. Other than ―a period of expectant observation‖ there were no other treatment options the [Dr E] should have discussed with the patient either at the time of initial diagnosis or when concerns were expressed regarding proceeding to surgery. 3. The most common complications of posterior fossa decompression surgery are: a. Haemorrhage b. Direct injury to posterior fossa neurological structures, cerebellum, brain stem and cranial nerves. c. Vascular injury arterial or venous with subsequent infarction of neurological structures, swelling, and development of secondary hydrocephalus. The frequency of the occurrence of respiratory depression as a complication of posterior fossa cranial surgery relates to at least in part the magnitude of the procedure undergone which in this instance would not be considered great; however as respiratory function control centres are within the posterior cranial fossa, respiratory depression can occur as a consequence of or indication of any of the identified surgical complications. 5 September 2012 54 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 4. I am of the opinion that it is the responsibility of the doctors involved in the treatment to specify post operative observations, and having regard to the nature of the surgery undergone, the recording of respiratory rate. I am of the opinion that a fall of oxygen saturation below 95% is significant and that any monitor alarm should be set at this level, and that should a fall occur to 95% saturation further action should be taken to identify and remedy the cause.‖ 55 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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Health and Disability Commissioner
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09HDC01565 - Health and Disability Commissioner

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