Without discussing the non-surgical alternatives with the mother, the consultant performed the procedure which involves cutting the skin under the tongue with scissors. Photo / 123RF
An eight-day-old baby required hospital treatment after a midwife attempted to remove tongue-tie by cutting the skin under its tongue with scissors.
The lactation consultant cut too deep and bleeding from the wound could not stopped, which required a trip to hospital.
The Health and Disability Commission launched a review into the incident and found the consultant breached the Code of Health and Disability Services Consumers' Rights.
The baby's mother rang the consultant, who was also a registered midwife, because she was having difficulty while breastfeeding.
The consultant identified the baby had tongue-tie and offered to perform a frenotomy on the child.
Without discussing the non-surgical alternatives with the mother, the consultant performed the procedure which involves cutting the skin under the tongue with scissors.
The mother was distressed and wanted to check her options with her LMC midwife but said she felt rushed into the procedure by the consultant.
Following the procedure, the baby started bleeding from the wound and could not be stopped and was required to be taken to hospital by ambulance.
Doctors repaired the cut in theatre and noted the incision from the consultant was deep and well into the tongue base.
They also found the cut caused significant bleeding from a branch of the lingual artery and was more resection than was needed.
Deputy Health and Disability Commissioner Meenal Duggal released a report into the incident and deemed the consultant to be in breach of the Code.
Duggal also found the consultant also failed to provide information for a consumer to receive and make an informed choice about an operation.
The consultant was required to report to the Health and Disability Commissioner outlining her discussion with an ear, nose and throat specialist and the changes made to her practice as a result.
Duggal suggested the consultant provide a letter of apology to the family of the baby and recommended the Ministry of Health consider formulating a consensus position on the efficacy of frenotomies.
Elderly woman taken to hospital following a failure to administer medication
A support worker has been found to be in breach of the Code after failing to administer medication to an elderly woman, resulting in the woman requiring surgery.
The 87-year-old woman lived in her own retirement village apartment with residential support and a home support agency was contracted to care for the woman.
The woman's regular support worker was unwell and another was instructed to assist the woman.
The new support worker had not received any medical training or competency checks in 10 years and had not received the training required to oversee clients taking warfarin.
On receiving a handover over the telephone, the support worker was not given instructions on where to find the woman's medication box or on administrating warfarin to her.
The support worker failed to administer the warfarin on her second and third day of providing support and failed to alert the home support agency of this.
A few days later the elderly woman was administered to hospital with an ischaemic left leg which required surgical intervention.
A report of the incident from Deputy Health and Disability Commissioner Rose Wall found the lack of warfarin administration bought on the ischaemia.
Wall recommended the support worker and home support agency write a letter of apology to the woman's family.
She also made adverse comments regarding the support worker for failing to notify the home support agency for failing to provide warfarin to the woman.