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

More documents

Recommendations

Info

Health and Disability Commissioner not know that Patient E was having problems with the placenta. They said that Dr Hasil had come in and asked who Patient E’s partner was, and had said that if he was going to be asleep to “just get him out”. They complained that Dr Hasil was rough when he tried to manually remove the placenta and did not explain what he was doing. They said that Dr Hasil was very arrogant and lacked communication skills, and that he had made their birthing experience very unpleasant. They also raised a number of other concerns — including the delay in Patient E going into surgery, that nothing had been organised when she arrived in theatre, that Dr Hasil had contributed to the blood loss by pulling at the placenta (not recorded), the paucity of medical notes, and a perineal tear during surgery (also not recorded). They also complained that Dr Hasil had provided no explanation after surgery and that Patient E had not been catheterised. On 4 May 2006, the DHB received the complaint from Patient E and her partner, and commenced an investigation. The DHB notified Dr Hasil of the complaint and that it had been forwarded to the Service Manager and Dr A to investigate. In a letter dated 17 July 2006, the CEO set out the results of the investigation. He stated that it revealed that Dr Hasil’s communication style had left Patient E and her partner feeling excluded and uninformed, and that Dr Hasil had expressed his sincere apologies for the lack of communication. The CEO’s letter said that Dr Hasil did not recall asking Patient E’s partner to leave the room; however, if he had, he sincerely apologised that his manner had upset them. Dr Hasil also apologised for any pain experienced from his examination of Patient E, but noted that it was usual to gently pull the cord in diagnosing a retained placenta. The CEO explained in his letter that Dr Hasil had made the decision that Patient E needed to go to theatre at 7.30am on 25 March 2006 and had immediately booked the theatre. At 8.15am, Dr Hasil had gone into theatre to find out when Patient E could be accommodated. The house surgeon had contacted theatre, but they were unable to send for Patient E at the time. At 8.50am, theatre staff had arrived to collect her. The CEO also stated that the anaesthetist’s comments that Patient E should have been in theatre earlier were not helpful, and that if he had been concerned about her condition, he should have spoken directly to Dr Hasil. The CEO also stated that the clinical records indicated that Patient E experienced birth trauma, which was repaired in theatre, and that Dr Hasil had not felt it was necessary to catheterise her. On receipt of the DHB’s response, Patient E felt that her complaint was being “swept under the carpet”, but decided it was not worth pursuing. However, following the media attention surrounding other complaints against Dr Hasil, she decided to follow up her complaint with the DHB. In a letter dated 3 May 2007, the CEO acknowledged Patient E’s and her partner’s dissatisfaction with the response to their initial complaint. The DHB commenced a reinvestigation into the complaint. In his letter, the CEO sincerely apologised for the series 34 February 2008
Opinion 07HDC03504 of events that had occurred. He stated that the investigation had revealed that Patient E felt Dr Hasil’s communication style and manner were rude and arrogant. Dr Hasil’s controlled cord traction technique to remove the placenta was in accordance with standard practice, but the CEO acknowledged that it was extremely painful. The investigation also revealed that theatre staff formally commenced weekend duties at 8.30am and they had been contacted and arrangements had been made for them to set up for Patient E’s operation on arrival. Although the midwife had telephoned theatre and requested that the start time of the operation be brought forward, the staff had not been able to respond to this request. The clinical records indicate that Patient E’s condition had deteriorated at 7.35am and that she had lost approximately 500ml of blood. Immediately following surgery, her haemoglobin level had been low, at 69g per litre, requiring blood transfusion. The DHB had been unable to establish when the perineal tear had occurred. Patient E remained dissatisfied with the DHB’s response to her concerns, particularly regarding Dr Hasil’s controlled cord traction technique, the perineal tear, the delay in getting to theatre, and the recording of the blood loss. On 25 May 2007, Patient E met with the staff involved to discuss her outstanding concerns. Patient E subsequently made a claim to the Accident Compensation Corporation (ACC) for a treatment injury. In July 2007 ACC accepted the claim for (1) hypovolaemic shock requiring blood transfusion due to delay in proceeding to theatre which was urgently required due to blood loss from retained placenta; and (2) perineal tear. ACC sought clinical advice from Dr Jenny Westgate, obstetrician and gynaecologist, who stated: “Delay in going to theatre for manual removal of placenta caused a large blood loss and need for 5 unit blood transfusion. Dr Hasil’s refusal to allow a Syntocinon infusion preoperatively is not acceptable management and contributed to the severity of the post partum blood loss.” Incident of 31 May 2006 (incident 7373) On 31 May 2006 at 1.30pm, Nurse A smelled alcohol on Dr Hasil when he arrived to do a gynaecology clinic. She advised her manager. She then confronted Dr Hasil, asking if he had been drinking. After he denied it, Nurse A told him he smelled of alcohol and Dr Hasil said that he had had “a bit” the night before. She checked whether he had been on call the previous night and found that he had not been. Nurse A stated that a short while after she confronted Dr Hasil about the smell of alcohol, she could no longer smell it. Since he had not been on call the previous night, she did not wish to pursue the matter as she believed “he was not at fault”. Her manager requested that Nurse A inform Dr A and write an incident report. An incident form was completed by Nurse A and reported to Quality and Risk Management and the Service Manager. She stated: “I could smell alcohol on Dr Hasil when he arrived to do a clinic. I informed [my manager] — this is the second time.” Nurse A’s manager said that she did not receive any feedback from the incident report. The Clinical Quality and Risk Advisor did not recall the incident form being received by the Quality and Risk team, and concluded that it had been sent when she was on leave or February 2008 35
Page 1: Dr Roman Hasil and Whanganui Distri
Page 4 and 5: ISBN 978-0-473-13288-0 Health and D
Page 6 and 7: Health and Disability Commissioner
Page 88 and 89:
Health and Disability Commissioner
Page 90 and 91:
Page 92 and 93:
Page 94 and 95:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
Page 146 and 147:
Page 148 and 149:
Page 150 and 151:
Page 152 and 153:
Page 154 and 155:
Page 156 and 157:
Page 158 and 159:
Page 160 and 161:
Page 162 and 163:
Page 164 and 165:
Page 166 and 167:
Page 168 and 169:
Page 171:
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?