A senior surgeon’s mistake during a delicate procedure resulted in his patient dying from a severe brain haemorrhage hours after the procedure.

Several experts raised “significant concerns” over the doctor’s competence after the 51-year-old woman’s death in May 2019, following a procedure to treat “abnormal” blood vessels.

The Health and Disability Commissioner (HDC) investigated after a complaint was referred from the coroner regarding the woman’s care.

The HDC said in a report released today that the surgeon, named as Dr C, had failed to comply with professional standards.

He was no longer working in a specialist field as a diagnostic and interventional neuroradiologist (INR).

Doctor recognised mistakes made

Dr C recognised that mistakes were made during what he described as an “extremely complex case”, but which independent reviewers described as him having “unnecessarily complicated the procedure”.

Several failures by Health New Zealand Te Whatu Ora, including a lack of clear guidelines for the actions to take when complications arose during angiography, contributed to the woman not receiving the required care and checks before her death.

Deputy Health and Disability Commissioner Vanessa Caldwell said the complaint to the HDC was supported by the woman’s partner, who was also concerned about the manner in which the surgery was carried out.

The anaesthetist became aware of "potential procedural difficulties" when a third doctor entered the room and asked if they were sure about the way in which they were handling the procedure. Photo / 123rf
The anaesthetist became aware of "potential procedural difficulties" when a third doctor entered the room and asked if they were sure about the way in which they were handling the procedure. Photo / 123rf

History of cardiac problems

The woman, who had been unwell from congenital cardiac issues, had surgery in 2012 to replace two of four heart valves.

Six years later, she was admitted to hospital with symptoms that turned out to be the result of a small brain bleed.

Because of concerns about cardiac failure, she was transferred to the high dependency area and treated for gastroenteritis, possible stroke and a condition called infective endocarditis, caused by inflammation of the lining of the heart and its valves.

Her breathing continued to deteriorate, and an acute kidney injury was diagnosed.

She was transferred to the Intensive Care Unit (ICU) where she remained until considered “unwell but stable enough” to be transferred to a ward.

Further investigation revealed a brain bleed and a likely infective mycotic aneurysm (MA), or abnormal swelling in the wall of a blood vessel in the back of her brain, which required urgent and high-risk cardiac surgery to replace the heart valves.

Risks discussed

In his statement to the coroner, Dr C said he had discussed with the woman the different treatment options and potential complications such as risks of stroke.

The doctor was the first operating surgeon.

After a brain angiogram, the consensus among those present (three neurosurgeons and two neurointerventional radiologists) was that the safest way to treat the MA was through the endovascular route.

The procedure was described as a “minimally invasive technique” used to treat blood vessel diseases from inside the vessel, typically using catheters, balloons and stents inserted through tiny incisions.

The option was conveyed to the doctor and he went ahead with the surgery with a second doctor, who told the HDC later their involvement in the angiographic procedure was “very passive”.

The anaesthetist became aware of “potential procedural difficulties” when a third doctor entered the angiography room to offer a second opinion about the intervention and asked the team if they were sure about the way in which they were handling the procedure.

The anaesthetist said this third doctor appeared concerned about decisions being made by the first doctor.

The third doctor told the HDC that in his opinion, the issue stemmed from when the first doctor was removing a microcatheter which had become temporarily stuck, and confusion over what had caused the vessel injury.

Likely cause of injury

In summary, Caldwell said the doctor failed to notice the microcatheter had been left in too long and had not used the correct counter-procedure when using force to remove it, which likely caused the vessel injury.

Following surgery the woman was transferred back to the ICU, but suffered an intracranial bleed six hours after surgery and, sadly, she died, Caldwell said.

A subsequent review by Health NZ showed concerns had also been raised with radiology management about the manner or technique in which the embolisation procedure was carried out, as well as the doctor’s reporting of the injury upon the woman’s return to ICU.

Given the concerns raised about the doctor, including that he was “operating independently with decision-making and staff felt unable to speak up”, Health NZ arranged for an independent review of his clinical practice by peers from a different hospital.

The review highlighted a “number of concerns” about his care of the woman, but acknowledged that her case would have been difficult and the treatment attempted was reasonable, given the risks.

Health NZ acknowledged that the doctor’s workload was significant at the time of the event, but stood by the findings of the reviewers in the independent report.

Doctor apologises; says impact ‘huge’

In his response to the HDC, the doctor again stated that he wished to pass on his condolences to the woman’s family and friends. He said the case had a huge impact on him personally and on his work, his career and on his family.

Caldwell said in finding both Health NZ and the doctor had breached a section of the health consumers’ code, the woman had been “very unwell” and the endovascular surgery was a “very high-risk procedure”, there were multiple failings in the system and in decisions made on the day of her surgery.

She said it was tragic for the woman, her partner and her extended family that they occurred at all.

Caldwell said the doctor’s vocational registration now excluded endovascular INR practice and he had limited his practice to diagnostic and general interventional radiology.

The Medical Council of New Zealand had required that he take part in an approved recertification programme relevant to his vocational scope.

Caldwell, in making a list of recommendations, commended staff for voicing their concerns to senior staff, the reviewers and Health NZ.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.