Unnecessary surgery after cancer misdiagnosis

Health and Disability Commissioner Ron Paterson has called for more robust systems to be implemented at Nelson Hospital after a man underwent unnecessary surgery.

The 67-year-old man underwent radical surgery in 2007 after he was diagnosed with prostate cancer by a locum senior pathologist.

The locum reported carcinoma on the right side of the man's prostate and he underwent a radical prostatectomy, Mr Paterson said.

The locum, who worked at the hospital for six days, did not get a second opinion on the diagnosis.

While the surgery was uneventful, the man experienced ongoing urinary incontinence.

Another pathologist reviewed the diagnosis and found no evidence of malignancy.

The man was then told he had undergone unnecessary surgery and made a complaint against the locum.

The commissioner said the locum had apologised to the man.

She said she would "carry the anguish of this error from this time onwards".

She said she was left to her own devices, and did not have the support of colleagues when it came to reviewing cases for surgery.

He quoted her as saying: "There were certainly times where I couldn't find anyone that could help with technical problems."

The hospital's clinical director said he made sure he checked how she was going during the time she was at the hospital and she always seemed fine.

Nelson Marlborough District Health Board (DHB) had also apologised to the man and as a result of its own investigation all pathologists had reviewed their practice.

Mr Paterson found the man had undergone unnecessary surgery and recommended that the DHB review its induction of locum pathologists.

He also recommended the DHB give further consideration to holding multidisciplinary team meetings to discuss pathology before major surgery.

A copy of his report had been sent to the Medical Council of New Zealand and ACC and would also be sent to the Royal College of Pathologists of Australasia, the Royal Australasian College of Surgeons, the Cancer Society of New Zealand and all DHBs.

Mr Paterson's report said the locum had since discontinued all surgical pathology as the primary reporting pathologist, and stopped doing locums and prostate work.

- NZPA