News Video | Policy | GPs | Hospitals | Medical | Mental Health | Welfare | Search

 

Failing to provide appropriate services to heart patient

Failing to provide appropriate services to man with cardiac anomaly

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.

ENDS


© Scoop Media

 
 
 
Culture Headlines | Health Headlines | Education Headlines

 

NZ Festival : The NZSO Goes To The Disco and more...

In the endless, anguished debates about how to make classical music more relevant to new audiences, proposals are often put forward to strip away certain elements – reduce the formality ... More>>

ALSO:

Howard Davis: Charlotte Yates' Mansfield Project

Katherine Mansfield's vapid verses are of even less interest than her over-rated short stories, but Yates has risen to the challenge of producing a fascinating compilation album by a variety of musicians to accompany her poetry. More>>

Howard Davis: Dazed & Confused by Beats

Beats is both a coming-of-age tale and a romantic movie about endings, set to a nostalgic backdrop of the disappearing tail of the UK's illegal rave scene. More>>

Howard Davis: And The Oscar Goes To … Parasite
For its deliciously dark wit and genre-bending ingenuity, Bong Joon-ho's latest movie has just won four out of a potential six Academy Awards, including Best Screenplay and Director. Only ten foreign-language films have previously been nominated for Best Picture and none have won before. More>>

Howard Davis: 1917's 1,000 Yard Stare

Sam Mendes has created a terrible and barbarous trek, one that we appreciate all the more for being catapulted right into the midst of this ear-splitting melee from the film's opening sequence. More>>

Howard Davis: 1917's 1,000 Yard Stare

Sam Mendes has created a terrible and barbarous trek, one that we appreciate all the more for being catapulted right into the midst of this ear-splitting melee from the film's opening sequence. More>>

Over 150 Productions: NZ Fringe 2020 Has Launched

The upcoming festival will be held at 40 venues all over Wellington Region from 28 February to 21 March, and includes every genre possible—theatre, comedy, dance, music, clowning, cabaret, visual art, children’s shows and more! More>>

ALSO:

 
 
 
 
 

LATEST HEADLINES

  • CULTURE
  • HEALTH
  • EDUCATION
 


 
  • Wellington
  • Christchurch
  • Auckland