Photo: Unsplash / RNZ composite
A brain surgeon who refused advice from his colleagues has been stood down after his patient died of a brain bleed post-operation.
A report by the Health and Disability Commissioner found his sarcastic remark to a fellow surgeon, who questioned him on his approach, “inappropriate”, and criticised a culture of silence when it came to questioning senior surgeons at the hospital.
The patient, who the report calls Ms A, then aged 51, received two heart valve replacements in 2012, and then in May 2019 was admitted to hospital with vomiting, diarrhoea and fever, accompanied by delerium and speech issues.
Scans revealed a brain aneurysm, and although she needed urgent cardiac surgery to replace her heart valves, doctors decided the aneurysm needed to be treated before they could operate on her heart.
A surgeon referred to in the report as Dr C performed endovascular surgery, with support from other doctors – but one of those doctors told the HDC that their own involvement was “very passive”, as Dr C was “very used to work[ing] by himself”.
An anaesthetic registrar who was in attendance told HDC they witnessed another doctor entering the room to ask Dr C, “Are you sure you want to do it like that?”
HDC heard from that doctor, who said when Dr C was removing a microcatheter that had become temporarily stuck, it “was not adequately controlled and surged forwards, injuring a more proximal vessel (causing a dissecting pseudo-aneurysm)”.
When he asked Dr C what he was going to do about the pseudo-aneurysm, and Dr C replied: “(W)hat pseudo-aneurysm.”
The woman was transferred back to the ICU following surgery, but those complications caused further bleeding in her brain, and she died six hours after surgery.
Dr Vanessa Caldwell, Deputy Health and Disability Commissioner, found despite the surgery being high risk, and Ms A being very unwell, “there were multiple failings in the system and in decisions made on the day of Ms A’s surgery”.
She says according to Health NZ, Dr C’s workload was “significant” at the time of the event, and “the dynamic of the team was such that no staff member felt empowered to speak up to [Dr C]”.
It said Dr C had a history of persevering despite recommendations from others, and a culture of staying silent had developed.
“Dr C reflected that he may have had an unconscious bias against his colleagues,” the report says, “due to their relative lack of experience”.
They had not worked together long, he said, and they were “still relatively unknown quantities” which “played a definite role in his willingness to take advice from them”.
Caldwell, in her report, finds his sarcastic remark – quoted variously in the report as both “(W)hat pseudo-aneurysm” and “What dissection?” – inappropriate.
“Dr C told HDC that this was made sarcastically in reference to the brain-bleeding because it was so obvious that an injury had occurred.”
She also criticised the quality of his handover to ICU staff post-surgery, which contained a lack of information about the injury’s severity.
Dr C was stood down from performing such surgeries, and last did one in May 2019. He accepted the findings of the HDC report, and extended his condolences to the family.
He said the case had had a huge impact on him personally, his work and his career, and on his family.
Caldwell said Dr C described being “burnt out”, and in her view, Health NZ had an organisational responsibility to staff its service safely.
She recommended a written apology to Ms A’s family from both Dr C and Health NZ.
Health New Zealand’s executive regional director for the central region, Chris Lowry, said Health New Zealand wished to extend its deepest apologies to the whānau of the patient for the loss and trauma they experienced.
A written apology had been provided, and changes were made following to strengthen systems and reduce the risk of it occurring again.
“The clinician involved is no longer undertaking these procedures,” Lowry said.
“We continue to work with the Health and Disability Commissioner to ensure appropriate processes are in place.
“We would like to assure the public that incidents like these are extremely rare, and that as in all surgeries, there is some level of risk. We remain confident in the quality of our care.”
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