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Surgical error and poor postoperative care 16HDC01466

Health and Disability Commissioner Anthony Hill today released a report finding a general surgeon and a DHB in breach of the Code of Health and Disability Services Consumers’ Rights for services provided to a woman who underwent bowel surgery.

The woman underwent a laparoscopic end colostomy as a first step to resolving gastrointestinal problems. The general surgeon operating did not identify that the incorrect end of the colon had been used to form the stoma. Despite the woman’s ongoing post operative symptoms, DHB staff did not adequately investigate and identify the error for 12 days. Corrective surgery was then carried out.

Mr Hill noted that wrong end stoma is a rare occurrence and that certain factors would have increased the risk in the circumstances of this case. However, he was critical that the general surgeon did not identify the error and that the woman’s post operative symptoms were not adequately investigated for 12 days. Mr Hill said that the woman "had displayed non-resolving clinical symptoms to the point where critical analysis ought to have precipitated action but did not". Mr Hill found there was an unfortunate combination of service failures which were a significant departure from the standard of care expected of a surgical service.

Mr Hill recommended that the general surgeon and the DHB each provide a written apology for their failures in the care provided. He also recommended the DHB audit compliance with its notification and reporting of adverse events.

A copy of the full report can be found on the HDC website:


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