A woman in her 70s died of septicaemia and bleeding complications after a surgeon inserted a catheter during surgery without her informed consent, the Deputy Health and Disability Commissioner has found.
Sepitcaemia is the clinical name for blood poisoning by bacteria.
Deputy Health and Disability Commissioner Carolyn Cooper found the surgeon breached the Code of Health and Disability Services Consumers' Rights, and said the situation highlighted the need for health professionals to provide adequate information to patients.
The woman was undergoing a planned procedure in 2017 when the catheter was inserted because of the severity of the woman's bleeding and the surgeon's findings. She was discharged home but presented to ED within 24 hours, with abdominal pain.
She was treated and discharged home again. The following day, she deteriorated again and was admitted to ICU but died of septicaemia and bleeding complications, Cooper said.
"This was a complex case with clinical risks, and in placing the suprapubic catheter (SPC), it would seem the surgeon believed he was acting in the woman's best interests," she stressed.
"However, the guidelines around suprapubic catheter use suggest patients should have a chance to discuss the risks and benefits.
"In this case there was no documented evidence of discussion with the woman about the possibility of SPC placement."
Cooper said this meant the woman could not make an informed choice about her treatment, adding that the risks to the woman were heightened because of her medical history.
Among other recommendations, both the surgeon and ED doctor are advised by Cooper to write apologies to the family.
A statement announcing the decision said "following these events, significant service changes have been made or proposed by Te Whatu Ora, and changes made by the surgeon and ED doctor to their practice".
"I am pleased to see the changes made in the practice of the surgeon and doctor, and changes and improvements made by Te Whatu Ora," Cooper said.
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