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

More documents

Recommendations

Info

Health and Disability Commissioner Dr C said that as the year went on, particularly around July–August 2006, Dr A expressed concerns to him about Dr Hasil. Dr A said that he was concerned for the safety of the department because he was not sure whether Dr Hasil “was up to it”. However, Dr C said that Dr A was not specific in his concerns — it was more about Dr Hasil’s general attitude towards clinical practice. Dr A showed particular concern at the time he was leaving Wanganui Hospital. Following his resignation, Dr A continued to supervise Dr Hasil, but expressed some concerns to Dr C about supervision because of issues regarding Dr Hasil’s clinical practice. Dr C’s response to the concerns was that if Dr A had specific concerns, he needed to raise them with the Medical Council. The DHB noted that the nature of the concerns raised about Dr Hasil through the patient complaints process, with the exception of the alcohol-related complaints, were similar to those raised about other senior clinicians. However, the DHB cannot recall any other occasion of a nurse notifying the team leader of safety concerns, as Nurse A did in May 2006. QUALITY OF CARE This section encompasses the information gathered in relation to the complaints from Patient A, Patient B and Patient C about the quality of care provided to them by Dr Hasil and Whanganui DHB. Overview of complaints In March 2006, Patient A consulted Dr Hasil at the DHB’s Family Planning Clinic regarding sterilisation. In September 2006, Patient A underwent a laparoscopic sterilisation under general anaesthesia for unwanted fertility. Five months later, she discovered she was pregnant. As noted above, Patient A made a formal complaint to the DHB about the failed sterilisation procedure. The complaint was the impetus for the DHB’s audit of patients who had undergone a laparoscopic sterilisation performed by Dr Hasil. On 6 March 2007 she complained to this Office. On 29 March 2007, my Office received a complaint from Patient B. In September 2005, Patient B had consulted Dr Hasil at the Gynaecology Outpatient Department regarding sterilisation. In January 2006, she underwent a laparoscopic sterilisation under general anaesthesia for unwanted fertility. About nine months later, she discovered she was pregnant. In February 2007, Dr B performed a repeat laparoscopic sterilisation. He noted that the Filshie clip was not on the right Fallopian tube. The third complaint was received from Patient C on 2 July 2007. Patient C had been referred to Dr Hasil with worsening abdominal pain and findings on CT scan consistent with left ovarian pathology. A subsequent pelvic ultrasound scan revealed cystic structures on both ovaries. Patient C understood that Dr Hasil would perform an exploratory laparoscopy/laparotomy and possibly remove the cysts. However, she signed a consent form for laparoscopy/laparotomy and possible bilateral oophorectomy. In September 2005, Dr Hasil performed a laparotomy and bilateral salpingo- 48 February 2008
Opinion 07HDC03504 oophorectomy 26 and adhesiolysis (cutting of abdominal adhesions). In May 2007, during a consultation with her general practitioner, Patient C was shocked to discover that both ovaries had been removed during the surgery. Dr Hasil’s response to the rate of failures On 26 February 2007, Manager C informed Dr Hasil of Patient A’s complaint and asked him to provide a response. In his letter to Manager C dated 27 February 2007, Dr Hasil indicated that there were aspects about the operation theatre that he considered to be “distractive and can cause some concerns”. He stated: “Nursing staff assisting to laparoscopic sterilisations, from my experience are doing this procedure [for the] first time, the instruments are often incomplete and assembled from different sets ad hoc and what is important — [is that] the applicator is not checked by appropriate gauge before using it. I do not want [to] blame anyone else for failure of this procedure, but I wish that such sensitive operation, from patient’s point of view, has to be performed carefully from ALL involved in laparoscopic sterilisations.” Dr Hasil had no explanation for the failure of the sterilisation operations he performed. He stated that he used the recognised sterilisation procedure as he has done for a number of years, and that his failure rate had been comparable to the accepted rate of one per 200 procedures. He explained that he had performed many laparoscopic sterilisations over 15 years, and that it was a straightforward operative procedure. Dr Hasil submitted that he had never previously had any difficulty with laparoscopic Filshie clip sterilisation procedures. He stated that during an operation at Wanganui Hospital in January 2006 he had had difficulty with the Filshie clip applicator, which had resulted in a bend in the applicator. He had advised the theatre staff that the applicator would need calibration. He further submitted that if he “was being supervised adequately at this time in theatre, the consultant obstetrician and gynaecologist present would have corrected [his] application of the Filshie clips”. Dr Hasil stated that the minor procedures, including laparoscopic procedures, generally attracted nursing staff who were absolutely new or junior, or a multi-skill nurse who did not practise in gynaecology. Dr Hasil was usually assisted by a junior doctor and the anaesthetist for laparoscopic operations was usually a medical officer. DHB investigation of Dr Hasil’s concerns Whanganui DHB carried out an investigation into the concerns raised by Dr Hasil. The Theatre Manager stated: “1. No nurses are permitted to scrub for any procedure without direct supervision and assessment of capability. 26 Bilateral salpingo-oophorectomy is the surgical excision of Fallopian tubes and ovaries on both sides. February 2008 49
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 102 and 103:
Health and Disability Commissioner
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?