A man went to hospital to have a routine procedure but died after the surgeon was unaware of his clinical history.

If the surgeon and Te Whatu Ora Nelson Marlborough had effectively communicated, the endoscopy team investigating possible gastrointestinal bleeding would have been aware the patient had previously had a lung removed to treat lung cancer.

But the surgeon told the Health and Disability Commissioner’s office in its investigation of a complaint into the man’s death, that even if he did know about the decade-old surgery, he still would have performed the colonoscopy.

During the procedure, the patient, aged in his 60s, suffered a peri-respiratory arrest and had to be intubated.

Medical staff found he’d suffered a perforation to his colon. He later died.

In her decision released today, Health and Disability Commissioner Morag McDowell found Te Whatu Ora Nelson Marlborough and the surgeon breached the Code of Health and Disability Services Consumers’ Rights in their care of the man.

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.”

The Code stated consumers had the right to co-operation among providers, to ensure quality and continuity of services.

The surgeon breached Right 4, that consumers had the right to expect services provided with reasonable skill and care.

“The patient had several co-morbidities including a prior pneumonectomy (lung removal) to treat lung cancer,” McDowell said.

“This history was relevant in guiding clinical decision making ... the surgeon was not fully aware of the patient’s medical history at the time the colonoscopy was performed.”

However, the surgeon told HDC there was a bedside handover for the patient and he was aware of the man’s recurrent admissions due to the bleeding.

One of those admissions was due to a heart attack and made the risk of surgery “dangerously high”, but it was believed to be necessary at that point to perform a colonoscopy due to the risks associated with allowing the bleeding to continue - in that it could lead to a second heart attack.

Either way, he didn’t believe the man’s lung removal operation from 10 years ago would have stopped the surgery from going ahead.

“The entirety of his co-morbidities were not appreciated. I do not believe that knowledge about his pneumonectomy 10 years prior would have changed the plan for colonoscopy or the process of the procedure.”

But McDowell said Te Whatu Ora had ineffective communication, there was no nurse-to-nurse handover from the ward to the endoscopy suite meaning the endoscopy team was unaware of the man’s prior pneumonectomy until serious difficulties were encountered.

“Oversights around communication and handover of care meant the endoscopy team was not able to consider the implications that the pneumonectomy might have on the sedation dose chosen and removed the opportunity for a different approach to the patient’s sedation and procedure.”

McDowell said where multiple clinicians and teams were involved in a patient’s treatment, particularly a patient with significant co-morbidities, “robust and open communication is the cornerstone of providing safe and effective care”.

“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,” 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.

Changes included amending the booking process so that acute endoscopies are performed by general surgery in the operating theatre, reviewing the safety checklist used prior to procedures, and including a section to highlight relevant co-morbidities and patients’ capacity to give informed consent and implementing a guided nurse handover policy for transfer between the ward and endoscopy team.

The man’s daughter, who laid the complaint, did not comment on the Commissioner’s findings.