Doctor didn't know about blood refusal

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A surgeon who operated on a woman who later died in hospital from blood loss was unaware she had signed a declaration refusing to receive blood products.

Health and Disability Commissioner Anthony Hill has released his report in to the death of the woman, referred to as Ms A.

He investigated the Nelson Marlborough District Health Board, a general surgeon and an anaesthetist in relation to the 2011 incident.

Ms A, a former Jehovah's Witness, had signed a document in 2010 that outlined her refusal of all blood products.

She underwent keyhole surgery to remove her gall bladder in 2011.

She explained her position on refusal of blood products in a pre-surgery meeting with a nurse.

However, when she met her surgeon, Dr C, there was no discussion around receiving blood because the surgeon said the chances of bleeding during the surgery was so low.

Dr C acknowledged that had he been aware of Ms A's views, his discussion with her prior to surgery would have been different.

"If you don't want to have blood then the important thing is to be fully informed about the consequences, what the options are should we get into trouble with bleeding and in lap choles, in the unlikely event that we get into bleeding, what the options are."

The surgery began, but Dr C was unable to get a clear sight of the gall bladder through the keyhole technique and moved on to an open surgery.

Dr C told Mr Hill that after the surgery there was a small amount of bleeding that he wasn't concerned about and he moved on to another operation.

The anaesthetist, Dr D, had read Ms A's notes before the surgery and was aware of her directive to not be given any blood products.

After the surgery, Dr D went to alert the surgeon that Ms A was bleeding.

The anaesthetist said when he initially told Dr C that the patient was bleeding, the surgeon said, "Well, give her blood," at which point he was informed of her decision.

Dr C asked Ms A, who was under sedation, whether she would accept blood, and she refused.

He contacted Ms A's mother, who refused to over-ride her daughter's wishes.

Ms A died from blood loss that evening.

Mr Hill found the Nelson Marlborough District Health Board breached the Code of Health and Disability Services Consumers' Rights by failing to have arrangements and systems in places that would efficiently communicate the woman's refusal of blood and blood products.

Mr Hill found Dr C breached the code when he failed to read the woman's notes sufficiently before beginning surgery.

The anaethetist Dr D failed to communicate the woman's refusal of blood with the clinical team, and also breached the code, Mr Hill said.

"The primary learning from this case is that material information must be communicated to senior members of the operating team before surgery," Mr Hill said.

Dr C no longer has a practising certificate from the Medical Council of New Zealand.