09HDC01565 - Health and Disability Commissioner

Opinion 09HDC01565
there was a general lack of awareness of the rare potential for severe postoperative
ventilatory respiratory failure, which meant specific monitoring for this was not
instituted;
the positioning of a curtain to prevent a night light shining in Mr A‘s face meant he
was not able to be readily and constantly observed;
handover was taken outside the SCU.
The RCA made seven recommendations to address the findings deemed to have
contributed to Mr A‘s death, and six further recommendations to address issues
identified in the course of the RCA but not directly related.
In correspondence to Mrs C‘s legal representative on 22 December 2009, the interim
general manager for the Medical and Surgical Services Division stated that:
―The recommendations made by RCA team acknowledge that the processes in
place for the postoperative care that [Mr A] received required strengthening and
weren‘t adequate for the detection, prevention or adequate management of the
respiratory failure that led to his death. The staff caring for [Mr A] were
functioning within those existing systems and whilst there are clearly components
of this care which we would wish to have done differently, it is the collective of
events within the established systems rather than actions of any individual which
led to the tragic death of [Mr A].‖
Report from Clinical Director, Neurosurgery
On 4 November 2009, Clinical Director for the Department of Neurosurgery
completed a report as part of the consultation regarding the RCA recommendations.
The following points are noted:
The Neurosurgery unit database shows that between 1996 and 2009, 514 posterior
fossa surgeries were performed, 48 of which were foramen magnum
decompressions. Of the 514 posterior fossa surgeries, a small number developed
postoperative haematomas requiring surgery, but none of these were patients who
had had foramen magnum decompressions. Mr A is the only patient among the 514
to have died from a probable primary respiratory cause.
The Clinical Director states that none of the surgeons in Canterbury DHB‘s
neurosurgical unit, or at any of the other neurosurgical units in New Zealand have
ever seen death from a probable primary respiratory cause occur in the absence of a
postoperative wound haematoma. He refers to a personal communication from the
Director of the Chiari Institute, New York, who also states he had never seen this
occur in the absence of a postoperative wound haematoma.
The Clinical Director states there is limited value in preoperative sleep studies as a
tool for predicting the likelihood of a postoperative problem with respiration. He
emphasises that the key is appropriate postoperative care. He outlines further
details in relation to this, including that a requirement for care should include
continuous pulse oximetry and continuous ECG monitoring for at least 24 hours
postoperatively, depending on the type of procedure and the patient‘s clinical state.
67 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.