Post-op care found wanting - HDC

Poor post-operative care by two Wanganui surgeons may have contributed to the death of an 85-year-old man who died 12 days after gall bladder surgery, the Health and Disability Commissioner has ruled.

The patient, known as Mr B, had complicating factors including bladder cancer, when he underwent the surgery at Whanganui Hospital in June 2006.

While the operation itself was uneventful, a T-tube draining the wound became dislodged the night before Mr B was due to be discharged from hospital. It was meant to be in place for a month.

A nurse noticed it had become dislodged and told a surgeon, Dr C, who happened to be visiting the ward at the time.

He told the nurse to cover the wound and arrange an ultrasound for the next morning. He asked the nurse to document the instructions and tell Mr B's surgeon, Dr D, in the morning.

Dr C called Dr D at his home that evening "as a professional courtesy" but did not get a reply.

Mr B was discharged the next morning without being seen by Dr D.

In the following four days a community nurse checked on Mr B's wound, which was deteriorating.

His GP sent him back to hospital as he became more unwell. After being readmitted, Mr B's wound came apart and a junior doctor noticed leaking intestinal fluid.

That night, Dr D examined Mr B and found the dislodged T-tube.

The next morning, Mr B underwent further surgery. He initially responded well but on the eighth day after his operation he collapsed and could not be revived.

A post mortem revealed Mr B died from peritonitis and an abscess on the abdominal wall.

In findings released today, the now former Health and Disability Commissioner Ron Paterson found that the care the Mr B in the days after his surgery was not up to standard and that there was poor communication between medical professionals at the DHB.

He said that Dr D had delegated aspects of Mr B's care to junior doctors in his team but that did not absolve him from his responsibilities.

Mr Paterson found that Dr D did not provide clear enough instructions about the management of the T-tube, that the medical reviews were inadequate, and that his notes were deficient.

As for Dr C, Mr Paterson found that even though he was not formally on duty the night he looked at Mr B's wound, he had a duty to follow up and inform Dr D's surgical team about the incident.

Dr C should not have relied on a nurse to convey the information, Mr Paterson said.

The Whanganui District Health Board did not escape criticism.

Mr Paterson found that there were "longstanding, unresolved problems in the working relationships within the (surgery) department".

Poor communication was a "key factor" that compromised Mr B's care, he said.

Both surgeons have reviewed their practices in light of the findings and have apologised to Mr B's family.

The Whanganui DHB has also apologised, and has taken steps to improve the quality and co-ordination of care.

- NZPA