Health and Disability Commissioner tells surgeon to apologise after removing the wrong section of a cancer patient’s lung

The man has cancer in his other lung but it cannot be operated on due to it being his only lung. Photo / 123RF

• A cardiothoracic surgeon mistakenly removed the wrong lung lobe from a cancer patient, causing severe consequences.
• The Health and Disability Commissioner ordered the surgeon to apologise and undergo further training.
• The patient, Mr A, now has inoperable cancer due to the error and subsequent surgeries.

A surgeon mistakenly removed the wrong part of a cancer patient’s lung when operating to remove a tumour, resulting in the patient eventually losing the entire lung.

Now, the man has cancer in his other lung but it cannot be operated on due to it being his only lung.

In a complaint to the Health and Disability Commissioner (HDC) about the man’s treatment in 2020, his daughter said he has had a difficult and painful recovery over the past three and a half years and has been unable to return to work.

“Beyond this pain and lost income, my father has not been able to do the activities of life that bring him joy, such as physical activities,” she said.

“Now he has cancer in the lower right lobe of his lung. Because of having no left lung, his cancer is inoperable.

“The consequences of this accident are severe for my father and our family.”

Today’s HDC report on the matter detailed how the patient, referred to as Mr A, was diagnosed with lung cancer in the left lower lobe of his lung.

A cardiothoracic surgeon, referred to as Dr B, operated to remove the tumour but subsequently, it was discovered that the left upper lobe had been mistakenly removed instead.

The man, in his 60s, required further surgery which resulted in a complete pneumonectomy, where the remainder of the lung was removed.

According to the report, Health and Disability Commissioner Morag McDowell identified several issues for investigation.

These included whether the surgeon provided the patient with an appropriate standard of care, whether he effectively communicated the outcome of the surgery performed and whether he provided appropriate information and obtained the patient’s informed consent for the surgery.

Dr Richard Bunton, head of the Department of Cardiothoracic Surgery at Dunedin Hospital, was asked to provide independent clinical advice on the case.

He told the HDC that the initial surgery, where the wrong section of the lung was removed, was a major error in judgment on the part of the surgeon.

Bunton said it ultimately caused the patient to lose the lung.

“The reasons why Dr B became disorientated and removed the wrong lobe really can only be answered by Dr B himself.

“It certainly is difficult to understand from a purely objective point of view how this could occur but clearly it did.

“Dr B was clearly disorientated at the time of surgery.”

Thoracoscopic surgery was done within a confined space with various telescopes and optics.

“However, there is no resigning from the fact that the result was due to a major error in judgment and removal of the wrong lobe in such a patient would be considered to be a severe departure from accepted practice,” Bunton said.

“It is hard to imagine how this could occur in the hands of an experienced surgeon.

Dr B rejected the mistake occurred because of disorientation or an error of judgment.

He said he was fully aware the procedure was a lower lobectomy, and he proceeded to remove the lobe that was visible on the right side of the fissure - which was the left lower lobe.

However, Dr B said neither he nor anyone else involved in the surgery were aware that a torsion had occurred, and that the lung had rotated.

He assessed the orientation of the lung at every stage of the procedure through a video monitor, and it was unfortunate that he did not recognise the torsion that occurred after the lung was inflated and deflated, Dr B told the HDC.

“Obviously I lost orientation due to torsion of the lower lobe during the VATS lobectomy and having had divided the inferior pulmonary ligament and vein.

“Mistakenly I performed right upper lobectomy thinking it was the lower lobe as the lung had twisted on itself 180 degrees.”

Dr B and Health New Zealand accepted the removal of the incorrect lobe of the lung should not have happened.

Health NZ told the HDC that Dr B had accepted “full and sole responsibility for the error in removing the incorrect lobe and that Dr B has unreservedly apologised to Mr A and his wife in person”.

Health and Disability Commissioner Morag McDowell investigated the complaint.

Dr B performed the patient’s second surgery eight days later.

During that procedure, he found a twisted left lower lobe and a lower lobectomy, completion pneumonectomy was undertaken.

The message was relayed to the patient’s wife, and it was explained that the left upper lobectomy was mistakenly undertaken a week prior.

Mr A was discharged five days later and a plan was made for him to be reviewed in the coming weeks by his GP and at the cardiothoracic clinic.

However, the cancer later returned and was now in the right lower lobe of his remaining lung.

Mr A went on to raise concerns with the HDC about the information provided to him before the second surgery.

He said Dr B did not inform him of the error in the first surgery until after the second surgery had been completed.

He said Dr B had told him the second surgery was required because the blood supply to the remaining part of his left lung had been compromised.

While the clinical records state Mr A was informed of the error two days before the second surgery, there was nothing to indicate Dr B had any further discussions with Mr A about the reasons for the second surgery.

There was also no record of what was discussed with Mr A about the error before the second surgery.

Dr B said he advised Mr A that he would let him know all the findings of the second operation once it was complete.

“I did openly disclose the details of the error and its consequences to Mr A and his family as soon as I finished the second operation.

“It was only at this stage that I could confirm that the wrong lobe was removed.

“The remaining lung was found to be in a ‘rotated position inside the chest’, the position explains how the error had occurred (due to torsion).

“I advised this to Mr A at this stage and I apologised.”

Health NZ said Dr B acknowledged that the cause for the second operation was not discussed with Mr A although the removal of the incorrect lobe of the lung was suspected at that time.

Ultimately that was confirmed only during the second surgery.

McDowell found Dr B breached the Code of Health and Disability Services Consumers’ Rights by failing to obtain Mr A’s informed consent and not providing him with the appropriate information.

She recommended Dr B provide Mr A with a formal written apology for the deficiencies in the care he provided, undertake an audit of his other surgeries to ensure there were no other similar events, and undertake further training.