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DHB and surgeon breached health code in heart patient's death

Fuseworks Media
Fuseworks Media

Health and Disability Commissioner Anthony Hill today released a report finding Capital and Coast District Health Board and a cardiothoracic surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide appropriate services to a man with a cardiac anomaly.

A man in his 70s had a cardiac anomaly whereby his right coronary artery did not originate from the usual place in the heart, and it followed a different course to that of most people.

The man needed surgery to replace his heart valve. However, the cardiothoracic surgeon performing the surgery was unaware of the man’s cardiac anomaly. During surgery, the surgeon placed a stitch through the man’s coronary artery, and this caused poor right cardiac function. The man died following the surgery, and the surgical error was identified at autopsy.

In the lead up to the surgery there were a number of opportunities for the anomaly to be identified:

- The anomaly was referred to in a number of documents made available to the surgeon before the surgery, including in a report on an angiogram (a diagnostic procedure used to visualise the blood vessels of the heart) and the angiogram images themselves.

- The man’s case was presented at a meeting of 10-20 cardiologists and cardiothoracic surgeons, including the surgeon (the Combined Cardiac Meeting or CCM). The attendees were provided with documents that included references to the man’s cardiac anomaly, and the angiogram images were viewed at the meeting, however the anomaly was not discussed.

- Two anaesthetists subsequently confirmed that they were aware of the anomaly during the surgery, but assumed that the surgical team were already aware of it, so did not discuss it with the surgeon during surgery.

The Commissioner was critical of the services provided to the man by the DHB. He found the cardiac anomaly was known by multiple people and recorded in multiple places in the DHB’s system and that there were numerous missed opportunities for the information to be communicated to the surgeon.

He considered the fact that the DHB did not require completion of a coronary diagram ahead of surgery, and that the purpose of the CCM was not clear to its participants, also contributed to these missed opportunities.

Mr Hill recommended the DHB:

- apologise to the man’s family;

- create terms of reference for Combined Cardiac Meetings;

- align their policy regarding coronary diagrams with national practice and ensure that documents completed between the CCM and the surgery are filed appropriately;

- provide training on the interpretation of angiogram images; and

- set an expectation that operating surgeons will read all pertinent information ahead of the surgery.

Mr Hill considered there to have been significant failures in the care the surgeon provided to the man, notably that he did not review the preoperative documentation comprehensively, interpret the angiogram images adequately, and identify the anomaly. Mr Hill was also critical of the surgeon’s intraoperative decision to administer antegrade cardioplegia and his documentation of his operation findings.

Mr Hill recommended the surgeon apologise to the man’s family and undertake training on angiogram interpretation. He also recommended the Medical Council of New Zealand consider whether a review of the surgeon’s competence would be warranted.

The full report for case 17HDC00159 is available on the HDC website.

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