“The amount of impact of this incident on all our lives has been beyond any words can express,” Ali said.
“I am really desperate for some help in getting a resolution and some insight as to what happened and how it can be avoided so that it doesn’t happen again.”
Their complaint, laid in February 2024, has bounced between the Health and Disability Commissioner and the Medical Council with no answer in sight.
“If the nature of this complaint is so complex that it is taking them so long to investigate, someone failed to do their job properly that day in the clinic, which has left a very able man disabled for life,” she said.
MacLean needed to get a tooth removed and an implant inserted.
He went through a specialist Auckland clinic for three procedures before the new tooth was in place.
The procedure
On May 25, 2023, aged 59, he arrived at the clinic at 12.10pm for his final appointment and was prepared for sedation. The practice knew he was a type 1 diabetic but he was in good health.
As part of the family’s ACC claim, the anaesthetist provided a full breakdown of what happened that day, which was provided to NZME by Ali and MacLean.
It said at 12.30pm MacLean was given 2mg of midazolam and then 50mg of propofol.
Ten minutes later he was given another 50mg of propofol. At this point, the dental surgery began with the dentist and founder of the clinic giving 4ml of adrenaline.
Between 12.40pm and 12.50pm McLean was given a further three aliquots of propofol (50mg each) before he was given 1g of paracetamol, 4mg of parecoxib and 8mg of dexamethasone.
At 12.59pm the dentist commented MacLean’s jaw was tight, which can indicate sensation.
MacLean was given a further 50mg of propofol. This was the last dose of sedation given.
Just one minute later his oxygen saturation, which indicates how efficiently the lungs and heart are transporting oxygen to the rest of the body, dropped rapidly from 99% to 47%. Anything under 90% is considered low.
Oxygen delivery to MacLean was increased to 6 litres/min from the default rate of 2 litres/min.
Oxygen saturation dropped further and oxygen delivery was upped to 15 litres/min.
When MacLean’s airway was checked the anaesthesiologist noticed he had profound bradycardia, where the heart beats too slowly.
She informed the room and immediately drew up and administered 600mcg of atropine and flushed it through with saline. CPR was needed to circulate the atropine and chest compressions began and an ambulance was called.
Clyde MacLean’s wife Shareen Ali has quit her job to care for him full time. Photo / Jason Dorday
The compressions increased the heart rate and CPR was stopped.
Then 10ml of 50% dextrose was given and 100% oxygen was delivered via a manual resuscitator. His chest was rising and falling with the hand ventilation but oxygen saturations did not increase.
An airway device called a laryngeal mask airway was inserted and it took approximately 10 minutes of vigorous hand ventilation for his oxygen saturations to increase. The paramedics arrived during this time.
The paramedics intubated Maclean and he was transferred to Auckland City Hospital, where he was transferred to ICU, before being transferred to Middlemore Hospital on June 2.
He was in a coma for 10 days before regaining consciousness but was paralysed, unable to eat or talk. Only after intense therapy has he managed to gain some movement back.
Ali has had to quit her job and cares for her husband full time.
HDC complaint based on expert opinion
The couple made a complaint with the Health and Disability Commission in February 2024.
The complaint, which has been seen by NZME, was acknowledged by the HDC four days later. It specifically referred to the actions of the anaesthetist.
The complaint stated a claim was lodged with the ACC for assistance. To assess the claim medical notes were obtained from the dental surgeon, the anaesthetist, Auckland Hospital Critical Care Unit and MacLean’s general practitioner.
Following those inquiries, ACC could not identify a reason for the serious brain injury.
ACC then sent MacLean’s file to an external expert anaesthetist, Dr Graham Roper, FANZCA Specialist Anaesthetist at Te Nikau Hospital, Greymouth, for his assessment of what could have happened.
Roper determined that the anaesthetist who was in attendance and responsible for MacLean’s sedation had made “some serious procedural errors at a critical time”, the complaint said.
Clyde MacLean suffered hypoxic brain injury in 2023 due to hypoxia and bradycardia. Photo / Jason Dorday
On page six of Roper’s assessment, it said at the point at which MacLean developed profound bradycardia and atropine was drawn up and administered, he was unconscious with very low oxygen saturations.
The low oxygen and the bradycardia indicated an impending cardiac arrest.
“Profound bradycardia in the presence of very low oxygen saturations is an emergency indicative of cardiac hypoxia and requires immediate oxygen delivery. This needed to be the priority and MacLean needed manual ventilation with enriched oxygen.”
Roper said the anaesthetist would be the most skilled in the team to provide the treatment and should have intervened while an alternative team member drew up the atropine and administered this under direction.
“With successful ventilation and oxygenation, the heart rate may have increased without the need for atropine.
“Time was lost when the anaesthetist spent time drawing up and administering medications without an alternative team member providing Mr MacLean with assisted ventilation.”
Roper’s report was the basis of MacLean’s complaint. Roper said he was unable to comment on his report as it belonged to ACC.
Complaint referred to Medical Council
An HDC spokesperson said following an assessment of the complaint it decided to refer it to the Medical Council in October 2024.
“The Medical Council are better placed to assess complaints which raise competency concerns about individual doctors.
“HDC advised Mr MacLean’s representative of our decision to close this complaint to allow the Medical Council to undertake an assessment of the concerns.”
The Medical Council then assigned someone to investigate the complaint.
Ali said she received a letter saying the council had done its investigations but was waiting for HDC to complete its investigation, despite the complaint being passed on from the HDC to the council.
“We didn’t hear from either organisation so we contacted HDC again to see what was going on,” Ali said.
In July 2025 the HDC advised Ali the complaint was referred back to the council, which said a decision would be made in February 2026.
“[We] never heard back from them, February came and went,” Ali said.
At the end of February, Ali contacted the council to seek an update on the decision, however, she was told in March no decision had been made.
“It’s been three years now and we still haven’t received any meaningful explanation or a response to our complaint,” Ali said.
When asked if the practice undertook an internal investigation or any disciplinary action, the founder of the Auckland clinic told NZME “we have done nothing wrong and I have nothing to say regarding this matter”.
The anaesthetist now works at a different practice.
The Medical Council’s primary purpose is to protect the health and safety of the public by ensuring doctors are competent and fit to practise.
A spokesperson for the council said privacy and natural justice considerations meant it could not confirm whether the council had received a complaint, notification or referral relating to any individual doctor, nor could it comment on any matters that may or may not be under consideration.
If the council did have concerns about a doctor’s competence, it may order a performance assessment, which considers whether a doctor is practising at the required standard.
“If a notification alleges that a doctor’s practice or conduct has affected a patient, council is required to refer the matter to the Health and Disability Commissioner.
“The HDC may also notify or refer matters to council where a complaint raises concerns about a doctor’s competence, conduct or fitness to practise, or where there may be a risk to public safety.”
The complaint was forwarded to the medical council on October 7, 2024.
“One year, eight months now and I would say that this is more than enough time for any credible organisation to have completed investigations on this matter,” Ali said.
“I am sure they will be interested to know what happened as well so that it doesn’t happen to any other patient.”
But Ali said with little communication from the Medical Council, she had lost hope.
“We didn’t find anything useful or there was no indication that any decisions would be made any time soon.
“After reading the letter, we lost hope that any useful outcome would come out of it.”
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.