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

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Health and Disability Commissioner that it had not actually been received and logged. However, it was stamped as received by Quality and Risk on 6 June 2006. The Service Manager said he was not aware of this incident. He said that the incident would have been brought to the attention of his fellow service manager or himself. In the report for June 2006 from Surgical and Support Services to the General Manager of the hospital, the Service Manager noted this incident. The report stated that “[a]n incident form was completed and forwarded to Risk Management and Head of Department re concerns in regards to a Gynae consultant”, and that no complaints had been received that month. Nurse A informed her manager that she handed a copy of the incident report to Dr A. Dr A said that the incident was brought to his attention. However, the only evidence was that Nurse A had smelt something. Dr A said that Nurse A partially retracted her statement of concern, saying that the smell might have been garlic, and that she was not absolutely sure it was alcohol she had smelled on his breath. Dr Hasil’s performance had not been impaired. Dr Hasil denied that he had been drinking while on duty or so that it would affect his duty, and there was nothing else to suggest that he had been other than Nurse A smelling something which she later said she was not sure was alcohol. Dr A said that when he raised the matter, Dr Hasil was quite angry and vehemently denied it, and that there was nothing else to suggest that he might have been drinking. Dr A noted that the incident was discussed with Nurse A, her manager and the Service Manager. Dr A considered that no further action was required. Patient F (complaint 1305) On 31 May 2006 Patient F was admitted to Wanganui Hospital for a planned induction of labour at 37 weeks’ gestation. The induction had been arranged by Dr Hasil. The induction of labour commenced on the morning of 31 May using prostaglandin gel. 20 Patient F did not go into active labour that day or overnight. On 1 June, Dr Hasil reviewed the plan of care and recommended a second dose of prostaglandin. Labour still did not establish. On 2 June, Dr Hasil attempted an artificial rupture of membranes, which was unsuccessful. Later that day, following a further assessment, a plan of care was discussed, and Patient F was advised that the induction of labour had failed and that an elective Caesarean section would be arranged for 9 June. Patient F was discharged from hospital with instructions to return if labour commenced or there were any concerns. On 3 June Patient F returned as pre-arranged for an assessment. She complained of a headache, had raised blood pressure, and was advised to remain in hospital. Patient F was unhappy with her maternity care and requested a Caesarean section. The midwife advised that there was no indication for an emergency Caesarean section at that time. On 5 June, Patient F felt unwell, her blood pressure worsened and Dr Hasil recommended an emergency Caesarean section. Patient F delivered a baby girl. 20 Later this day Nurse A reported that she found Dr Hasil smelling of alcohol. 36 February 2008
Opinion 07HDC03504 On 22 March 2007, Patient F made a verbal complaint to the DHB. She stated that it had been extremely traumatic for her over the five to six days during the admission. She alleged that Dr Hasil was technically wanting and had behaved inappropriately throughout. Patient F said that when Dr Hasil tried to artificially rupture the membranes, he “tore [my] insides”. She said Dr Hasil had risked her life and the baby’s. Patient F stated that Dr Hasil had screamed in theatre, and in the delivery suite he had been shaking, sweating and was rough. He had told her about his personal problems. She said that it was clear that the nursing staff and midwives were uncomfortable with his behaviour. She wanted to know why the nurses did not report his behaviour. Patient F also raised concerns that parts of a copy of the clinical record of her hospital admission, which were forwarded to her, were missing. On 23 March 2007, the DHB wrote to Patient F, acknowledging receipt of her complaint and saying that it would be investigated. In a letter dated 26 April 2007, the CEO informed her of the outcome of the investigation. The CEO referred to a report from the Head of Midwifery, who on several occasions was also present when Dr Hasil assessed Patient F’s condition and formulated a plan of care. The Head of Midwifery’s opinion was that the induction of labour was in accordance with standard practice. The Head of Midwifery’s view was that Dr Hasil had tried very hard to maintain the balance between clinical indications for induction and Patient F’s wish to birth the baby sooner rather than later. The investigation also involved interviewing theatre staff and the midwife involved. The CEO stated that no one recalled the specific behaviour described by Patient F. Furthermore, as Dr Hasil was no longer working for the DHB, the allegations could not be addressed with him. However, the CEO apologised for any inappropriate behaviour by Dr Hasil. A complete copy of the clinical record of her admission was forwarded to Patient F. In conclusion, the CEO stated that the investigation revealed that the plan for care was communicated, discussed and agreed upon with Patient F and her partner, and that the plan followed usual practice. The CEO explained that inductions can and do fail leading to emergency Caesarean sections, and that vaginal trauma may occur during examinations and attempts to rupture membranes. Furthermore, the investigation found that timely surgical intervention occurred shortly after clinical signs and symptoms indicated a worsening condition. Midwife D (incident report 7096) Midwife D is a registered midwife working at a nearby rural health centre. If she had any concerns about a client, she would usually discuss them with the obstetrician on call. On 15 June 2006, Midwife D reported an incident that took place on 11 June 2006 at 4.30pm, in which a client was booked for an induction of labour on 12 June 2006 when she was 13 days overdue. The client had pre-laboured since 10pm on 10 June and was exhausted, anxious, vomiting and dehydrated. The client and her family wanted to have something done about the labour. Midwife D felt a sleeping tablet or pethidine was not going to provide relief so she requested that the woman be reviewed at Wanganui February 2008 37
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