Surgeon ordered to apologise to patient after operating on the wrong part of her spine
An orthopaedic surgeon has been told to apologise after he operated on the wrong part of a patient's spine and didn't tell her.
Health and Disability Commissioner Anthony Hill's decision, released on Tuesday, found the surgeon breached the code of patient's rights.
The woman, who was 51-years-old at the time, was referred to hospital after experiencing worsening back pain in May 2013.
After a diagnostic MRI scan, the surgeon, referred to as Dr C, advised the patient she needed a herniated disc removed - called discectomy surgery - at level 4/5 of her spine.
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During the operation, Dr C found a "large amount" of scar tissue, and identified the level of the spine on which to operate using an X-ray image intensifier - standard procedure, according to the Health and Disability Commission decision.
But a follow-up MRI in June showed the surgeon appeared to have operated on discs at spinal level 3/4, not level 4/5.
In the meantime, the woman contacted Dr C after experiencing nerve pain and faecal incontinence. A month later she was back at the hospital's emergency department due to back pain.
In August, the woman, known as Ms A, was seen for a post-operative review. Dr C finally saw the report on the MRI scan that had been taken in June, and told the commissioner he was "shocked".
However, he did not discuss the scan report with Ms A as he thought it was important to confirm the situation clinically before discussing it with her, the decision stated.
He also did not contact the radiologist who conducted the scan, because he considered that "clinical clarification with the aid of spinal steroid injections would be useful to resolve any uncertainty".
She was admitted to hospital for steroid injections and discharged the same day, with an outpatient review planned for six weeks' time.
No follow-up appointment was organised by the DHB as the normal process of sending a request to arrange a booking was overlooked.
In the interim, Ms A asked for a second opinion through her GP.
After a second orthopaedic surgeon reviewed the scan, it was discovered that Dr C had operated on the wrong level.
The commissioner found that the surgeon took "appropriate clinical measures" prior to surgery to identify the right spinal level on which to operate.
However, it was clear from the relevant MRI scan that required "decompression" of the area of the spine had not been performed, Hill said in the decision.
"In the circumstances, including Ms A's ongoing symptoms, Dr C is criticised for not seeking further advice from colleagues and/or the radiologist about the interpretation of the scan at that stage".
Commissioner Hill found Dr C "did not provide services to Ms A with reasonable care and skill," in breach of Right 4 (1) of the Code of Health and Disability Services Consumers' Rights.
"Dr C failed to advise Ms A that the MRI report indicated that it was possible that he had operated on the wrong level of her spine, and that he intended to use the steroid injections to seek clarification in this regard.
"This was information that a reasonable consumer in Ms A's circumstances would need to receive to make an informed choice or give informed consent to the proposed further treatment.
"Accordingly, Dr C breached Right 6 (2) of the Code," the decision read.
The commissioner recommended that the surgeon consult with orthopaedic peers and consider adding screening with image intensification prior to incision to his clinical regimen, in an effort to ensure the issue was not repeated.
Hill also recommended the surgeon "undertake a review of his process for providing consumers with information during the surgical consent process and post-operatively", and apologise to the patient within three months.