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

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