A man died in Nelson Hospital after a colonoscopy was performed without surgeons knowing the man only had one lung.
The Health and Disability Commissioner (HDC) has found that Te Whatu Ora Nelson Marlborough, previously known as Nelson Marlborough DHB, as well as one of its general surgeons, failed in their duty of care for the man.
The findings, released on Monday, say the man, a father in his 60s, presented to Nelson Hospital’s Emergency Department where he was treated for a heart attack in 2018.
After two more visits during the following fortnight, he underwent an acute colonoscopy to investigate ongoing gastrointestinal bleeding.
During the procedure he suffered a peri-respiratory arrest and arterial bleeding and had to be intubated.
He was admitted to the Intensive Care Unit (ICU).
It was later discovered that he had suffered a perforation to his bowel during the surgery which then led to sepsis.
“The family were notified of these findings and made aware of the diagnosis of sepsis due to bowel perforation and that this was certainly related to the bowel wall being damaged during the colonoscopy,” NMDHB told the HDC.
“In consultation with the ICU team and family a ‘not for resuscitation’ in the event [Mr A] suffered a cardiac arrest was jointly decided.”
The man continued to deteriorate, and he subsequently passed away.
Commissioner Morag McDowell found Te Whatu Ora Nelson Marlborough and the surgeon breached the Code of Health and Disability Services Consumers’ Rights (the Code) in their care for the man.
The patient had several co-morbidities including a prior lung removal to treat lung cancer.
This history was relevant in guiding clinical decision making. However, the surgeon was not fully aware of the patient’s medical history at the time the colonoscopy was performed.
McDowell concluded that Te Whatu Ora Nelson Marlborough did not communicate effectively to ensure the coordination of the man’s care.
In particular, there was no nurse-to-nurse handover from the ward to the endoscopy suite and the endoscopy team was unaware the man only had one lung until serious difficulties were encountered.
Oversights around communication and handover of care meant the endoscopy team were not able to consider the implications that the missing lung might have on the sedation dose chosen and removed the opportunity for a different approach to the patient’s sedation and procedure.
“While individual staff members hold some degree of responsibility for their failings, I consider that the deficiencies outlined indicate a service level communication breakdown at Te Whatu Ora Nelson Marlborough, for which it bears responsibility at an organisational level,” McDowell said.
McDowell found the surgeon in breach of the Code for failing to review the man’s clinical notes prior to the procedure.
“As this Office has stated previously, the onus is on the clinician to ask the relevant questions, examine the patient and keep proper records,” she said.
McDowell made a number of recommendations including for Te Whatu Ora Nelson Marlborough and the surgeon to provide written apologies to the patient’s whānau.
However, she also acknowledged that significant and useful internal recommendations have already been undertaken by Te Whatu Ora and the surgeon as a result of their own review of these events.
Te Whatu Ora Nelson Marlborough accepted the proposed recommendations.
