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Deterioration and delay in opening a second operating theatre - Health and Disability Commissioner

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Fuseworks Media
Fuseworks Media

The Office of the Health and Disability Commissioner today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to identify a woman’s deterioration and open a second operating theatre to ensure that she received timely surgery.

The woman, in her forties at the time, had plastic surgery to reconstruct her upper jaw area following surgery to remove a tumour years earlier. Four days after the reconstructive surgery the woman experienced pain and swelling in the upper jaw area and was waiting for surgery to wash out the wound. When the woman was taken to theatre for surgery, instructions regarding the monitoring of her facial flap, the transplanted tissue and bone, were not handed over to theatre staff, as it was anticipated that the woman would be first in for surgery.

The woman’s surgery was delayed twice by two other urgent cases. She was transferred to the post-anaesthetic care unit to await surgery and there was confusion between staff as to who was responsible for monitoring her. The woman was left unattended and her condition worsened. Approximately six hours later, a second operating theatre was opened and the woman received surgery. During surgery, the woman’s condition deteriorated and she was transferred to ICU postoperatively.

Former Commissioner Anthony Hill identified a number of failures in the services provided by the DHB, including inadequate communication and handover between nursing staff; inadequate monitoring of the woman while waiting for theatre; and inadequate policies and procedures relating to after-hours acute surgery and handover of care between the ward and theatre staff.

"It is extremely concerning that despite the nature of [the woman’s] condition, which required regular monitoring, no one staff member took steps to monitor [the woman], check whether she needed any pain relief or had any other needs, or follow up with her surgical team," Mr Hill said.

Mr Hill also stated that it was his expectation that when staff transfer the care of a patient to another clinician, a complete handover should occur, particularly where regular monitoring of a patient was so important.

Mr Hill recommended that the DHB audit patient waiting times for acute surgery on the weekend, and the monitoring of patients while awaiting surgery. He also recommended that the DHB provide an update in relation to its review of surgical policies, and provide a written apology to the woman.

The full report for case 17HDC01248 is available on the HDC website.

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