Surgery botch-up not grave, says DHB

A botched bowel surgery at Wairau Hospital in May last year which saw a piece of a woman's bowel wrongly stapled is not considered serious enough to be included in the annual sentinel and serious events report by the Nelson Marlborough District Health Board.

Operations on a wrong toe, an internal bladder procedure and unnecessarily removing a man's prostate were considered serious enough for inclusion in the report.

A serious adverse event is defined as one that requires significant additional treatment but is not life threatening and has not resulted in major loss of function.

To be classified as a sentinel adverse event the mistake must have been life threatening or led to an unanticipated death or major loss of function.

As a result of the May 16 botch-up at Wairau, the woman had to endure two major surgeries within three days and surgery at the hospital was halted for weeks afterwards, with many patients having to travel to Nelson.

Asked why the woman's bowel operation was not included in the report, chief medical officer Andre Nel said the events reported had to fall within certain parameters to get a nationally consistent framework.

"It's a focus on systems, a no-blame focus," he said. "We are regretful that we have had any of these events and mindful of the effect it has on patients."

Two weeks after last year's "adverse event", surgery at Wairau was halted as the locum surgeon involved withdrew from his contract by mutual agreement and other surgeons were on leave.

From July 2007 to June 2008, 258 people throughout the country's hospitals were involved in adverse clinical events that were actually or potentially preventable. Seventy-six of them died during admission or shortly afterwards, although not necessarily as a result of the event.

Two of those deaths were in the Nelson-Marlborough region.

One was the misdiagnosis of an intellectually disabled Nelson man after a car accident last Easter.

Lionel Jenkins Holman, 70, was found dead at his Stoke home after being discharged from Nelson Hospital's emergency department.

A post-mortem found he died days later from bronchial complications that resulted from injuries he suffered in the crash.

The report said the man's emergency care was of an acceptable standard but the event raised opportunities for improvement, including educating staff about the level of care available in community homes and communication with people who have an intellectual disability.

It was recommended the emergency service introduce a policy that patients with abnormal vital signs, in the setting of trauma, be reviewed by a senior doctor.

The other death was of a mental health patient who committed suicide.

The client was on three hours' leave from a care facility at the time of the incident. The quality improvement committee found that the care provided to the client was of a good standard and all factors were taken into account when allowing the leave.

Of the three serious events, one case involved a patient who was put through a bladder examination twice. The urologist was unaware the procedure had been performed earlier because the patient's record had not been updated.

The method of filing patient records has been reviewed as has secretarial support to the urology service.

Another patient underwent "wrong site" surgery when the surgeon commenced incision on the second toe instead of the third. The surgeon had not followed final pre-surgery checks; notes on the clinical record did not mention the error and did not have the surgeon's name written clearly.

Another serious case listed a patient who had his prostate removed and suffered "post operative consequences". The mistake was based on a biopsy report which indicated cancer, but tissue tests after the procedure revealed no sign of it. Now all prostate biopsies are read by two pathologists. This case is the only one on the report being investigated by the Health and Disability Commissioner.

Other cases being considered by the commissioner but not included in the serious and sentinel report is that of a Marlborough mother of three.

Suzanne Wadsworth's brain tumour was not detected early enough due to health board MRI waitlist changes and she has asked the commissioner to inquire into her case, as has Nelson woman Su Wyatt, who has also laid complaints with the health board.

Ms Wyatt alleged Alexandra and Nelson hospital staff misdiagnosed her 77-year-old mother and withheld food and liquids from her for almost five days last year.

- The Marlborough Express