Brain surgery patient died after 'sub-optimal care'

19:53, Sep 24 2012

A young man who died after elective brain surgery received "sub-optimal" care, the Health and Disability commissioner has found.

In early 2009, a 21-year-old man died in the Canterbury District Health Board's neurosurgery unit after elective surgery to relieve pressure on his brain.

Before the operation, a trainee neurosurgeon met the man to discuss the surgery and get his consent. The man was unsure about whether to go ahead and later that day, he met his consultant neurosurgeon "Dr E", the commissioner's findings released yesterday said.

Dr E did not directly tell the man he could die from the surgery, instead using what he called his "plane flight analogy" consent technique.

"The basics were that if you fly from Christchurch to Sydney, you expect that you arrive safely the majority of times. However, there is a small chance that for whatever reason, the plane crashes into the Tasman . . . Therefore if you do not want to crash, you should not fly in the first place. Otherwise trust the plane, the pilot and co-pilot and take the flight," Dr E told the investigation.

The man accepted this, signed a legal document stating the risks and decided to go ahead with surgery, which was performed the following morning. Initially, the man's recovery seemed to progress as expected.


About 7am the next day, the man's overnight nurse reported no concerns in her handover.

After the handover, the new shift nurse arrived but did not initially see the man because the curtains were closed around his bed.

About 7.30am, the nurse opened the curtains and found the patient unresponsive, his face and skin "grey and waxy".

Attempts to revive the man failed and he was confirmed dead at 8.15am.

In yesterday's decision, Health and Disability commissioner Anthony Hill said the DHB did not "provide services of an appropriate standard because of sub-optimal processes and practices in the neurosurgical unit".

Concerns included a conflict between post-operative monitoring instructions and ward protocol, failure to check and/or document the patient's respiratory rate and that close observation of the patient stopped at nursing handover rather than following medical review.

Fairfax Media