Importance Of Reading Patient’s Notes Prior To Surgery Highlighted

Deputy Health and Disability Commissioner, Deborah James, has found a surgeon did not provide services of an appropriate standard after failing to ensure that he had all relevant information before performing surgery.

A woman’s left ureter (a narrow tube that carries urine from the kidneys to the bladder) was inadvertently injured during hysterectomy surgery. The surgeon did not read the clinical notes or the radiology report immediately prior to the surgery, and did not remember that the woman had a unique ureter condition, with two ureters draining from her left kidney into the bladder, rather than the usual one.

The surgeon accepted that he had caused the woman’s injury during the surgery and acknowledged that it is possible that the injury could have been prevented if he had reviewed the documentation, as was his normal practice. In her decision, Deborah James determined it was not reasonable for the surgeon to perform the surgery without having reviewed the relevant documentation.

"A surgeon needs to read the notes to the extent necessary to be satisfied that, as the operating surgeon, they have all of the information that they need to know."

As a result Ms James found the surgeon breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights - the right to have services provided with reasonable care and skill.

Ms James recommended the surgeon provide a formal written apology to the woman. She also recommended the surgeon continue to adopt the changes made since the incident to ensure clinical notes and preoperative consultation notes are reviewed prior to surgery being performed and risk factors are noted on the consent form.

The Deputy Commissioner acknowledged the effect this care had on the woman, and suggested the providers consider coordinating a restorative meeting.

Editors notes

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

Names have been removed from the report to protect privacy of the individual involved in this case. We anticipate that the Commissioner will name DHBs and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. HDC’s naming policy can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

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