Roman Hasil and the Whanganui DHB - Health and Disability ...

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Health and Disability Commissioner had had this information. I believe that the initial action taken by the DHB was appropriate under the circumstances, but there should have been more active, ongoing support. A further alcohol incident occurred on 31 May 2006. This was reported, but no action taken. In view of the previous incident in March, I think that further supportive action should have been taken at this point. The third alcohol incident occurred on 5 October 2006. Following this incident, Dr Hasil was placed on sick leave and received the appropriate treatment. I do not believe that Whanganui DHB did respond adequately to the earlier alcohol issues — particularly as there did not appear to be a plan for ongoing support and monitoring following the first incident. It is likely that his inappropriate alcohol use significantly contributed to his clinical judgement. 6.2 Staff concerns — there were several concerns about Dr Hasil raised by staff through incident reports and through discussion with [Dr A]. These issues covered both technical and behavioural aspects of his care. There were particular concerns raised by Outpatients. Although note seems to have been taken about these issues there was no evidence of a systematic response to address them. 6.3 Patient complaints — specific patient complaints were responded to appropriately, but there is no clear evidence of processes to improve the issues — both individual and systematic — raised as a result of the complaints. 6.4 The number of failed sterilisation procedures — there does appear to be a failure to identify a pattern of failed sterilisation procedures, beginning in April 2005. – [Dr A] was aware of the first failure [Patient H] on 10 April 2006, and arranged for her to be seen by Dr Hasil. She did not proceed with a second operation. – The second case was identified on 11 April 2006 and was followed up by [Dr A]. He met with Dr Hasil and discussed the issue with him. – The third case was identified by [Dr B] via a letter from the patient’s GP in July 2006. – The fourth case was referred to Whanganui DHB by her GP for a repeat sterilisation on 10 November 2006. She was subsequently seen by [Dr B] on 9 February 2007. – Finally, the fifth case [Patient A] made a verbal complaint after recently discovering she was pregnant after a tubal ligation performed by Dr Hasil. Whanganui DHB began its investigation shortly after this complaint. There was enough evidence through this process to have identified the failed procedures earlier. The first two cases were identified by [Dr A] in 2006 and he did follow up with Dr Hasil emphasising the importance of correct clip application. The second two cases were referred to [Dr B] from GPs in July and 156 February 2008
Opinion 07HDC03504 November, although not seen by him until later. There is no evidence to suggest that [Dr B] was aware of the first two failures. In the absence of regular review and audit of procedures, the pattern of failed tubal occlusion was not appreciated until the DHB received a complaint related to a failed procedure in mid-February 2006. At this stage a full investigation was instigated, which was entirely appropriate. 7. Please comment on the appropriateness and adequacy of the systems in place to deal with performance issues, complaints and incidents regarding Dr Hasil. Whanganui DHB has a clear and robust patient complaints policy, and it appears from the material available to me that in general this process is adhered to. The internal incident reporting process also appears to be functioning satisfactorily, although I have not seen the policy. 8. Did Whanganui DHB appropriately monitor Dr Hasil’s performance during his employment? There was not a formal process in place to monitor Dr Hasil’s performance. He was supervised and had the opportunity to attend the regular obstetric and gynaecology quality and team meetings, but his attendance at these were irregular and formal peer review did not occur. An assumption was made that he was capable of functioning at an SMO level, and in effect was functioning as an SMO. No formal performance or quality objectives were established, but in fairness, this does not occur regularly at SMO level nationally. 9. Did Whanganui DHB appropriately audit Dr Hasil’s procedures during his employment? Whanganui DHB did not audit Dr Hasil’s procedures until the issues related to his performance were raised. During his employment there was discussion with his supervisor, and he met with his superior to discuss issues of appropriateness of diagnoses and treatment, but it was not until he had stopped working that a more formal assessment was made by [Dr B]. 10. Did Whanganui DHB appropriately contact the Medical Council of New Zealand when concerns about Dr Hasil came to light? Whanganui DHB did contact the Medical Council when the concerns related to alcohol were raised. The DHB also contacted the Medical Council when the issue of failed sterilisations came to light. 11. Whanganui DHB became aware of four failed sterilisation procedures by November 2006. Please comment on the adequacy and timeliness of Whanganui DHB’s response. Although individuals in the DHB were aware of the failed sterilisations, I can find no evidence that the DHB was aware at that stage. [Dr A] was aware of two cases and had discussed the first of these with Dr Hasil. [Dr B] was also February 2008 157
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