A system of alerts on the medical records of patients who may have had the fatal brain disease CJD was given up five years before surgery on an undetected case led to others being put at risk.
The revelation is contained in an unpublished report by the Health and Disability Commissioner at the time, Ron Paterson. He did not find fault with the surgeon who treated the woman, nor the Auckland District Health Board, but he did express concern about the alert system.
In a letter to complainant Monique Lambermon - mother of Danielle, one of the 43 patients potentially exposed to Creutzfeldt-Jakob disease through sterilised and re-used instruments - he said it was concerning that the DHB, prior to quitting the alert system, had apparently not conducted a review of "the level of risk, the effectiveness of alerts and other relevant factors".
In 2001, the health board's neurosurgery service began placing alerts on the files of new neurosurgery admissions who had also been admitted for neurosurgery before 1987. This was because there had been cases, including two reported in New Zealand, of patients developing CJD after a potentially infected product called Lyodura was implanted during neurosurgery, to patch part of a membrane covering the brain and spinal cord.
In 2002-03 the DHB introduced a new electronic records system but the alert system for CJD risk "was not carried over", Mr Paterson said.