Health and Disability Commissioner Anthony Hill today released a report finding Wairarapa District Health Board (DHB)
and an orthopaedic surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for
failures in the care provided to a man during knee surgery.
During knee surgery the surgeon applied Betadine with alcohol on the edge of the man’s wound to minimise the risk of
infection. The surgeon then applied diathermy without waiting for the alcohol solution to dry first. As a result, the
man’s leg caught fire and he sustained burns.
At the time of the incident, DHB staff had a limited awareness of the risk of fire during surgery, and there was a lack
of appropriate guidance in the DHB’s policy in relation to fire hazards. Mr Hill considered that the fire was a service
failure directly attributable to the DHB as the service operator.
The surgeon failed to follow the DHB’s guideline regarding the use of alcohol-based solution and diathermy. While the
guideline did not discuss specific fire hazards, it did state that alcohol-based solutions must not have contact with
diathermy plates. The surgeon failed to follow the guideline by allowing the diathermy plates to make contact with the
alcohol-based solution. Mr Hill found that the surgeon failed to provide services to the man with reasonable care and
skill.
Mr Hill recommended that the DHB and the surgeon apologise to the man. Mr Hill recommended that the surgeon undertake
further education and training on fire hazards in operating theatres. Mr Hill recommended that the DHB confirm the
implementation and effectiveness of its new policy that forbids the supply of any alcohol-based solution to the
operating team until after diathermy has been disabled, prepare a fire hazard policy, audit compliance with the Aseptic
Technique Surgical Skin Preparation Clinical Guideline, and arrange training for its staff on the fire hazard policy and
the guideline.
The full report for case C17HDC02431 is available on the HDC website.
4 November 2019
ENDS