A man's throat caught fire during a voice box surgery in early 2020, a report into the incident released today revealed.
The incident occurred on February 17, 2020.
The man, aged in his seventies, was diagnosed with squamous papilloma — which appears as small benign (non-cancerous) growths — in 2012. He was undergoing surgery for a recurrent issue caused by the condition when the incident occurred.
He'd previously had 10 surgeries for similar issues and on one occasion, his oxygen levels dropped.
"To manage that risk, his doctors arranged to use special ventilation and oxygenation therapy," a statement from the office of the Health and Disability Commissioner explained.
"The use of this therapy carries a safety risk given oxygen combined with ignition and fuel sources can cause fires.
"The higher the oxygen concentration, the greater the risk and intensity of the fire."
During the surgery, a laser was used to treat the growths and the risk was managed appropriately by lowering the oxygen concentration.
But when the surgery was almost over, the surgeon noticed a small area of disease.
They began to treat it using a high frequency electrical current (monopolar suction diathermy), as opposed to a laser.
"The anaesthetic team were unaware that the surgeon had started using diathermy so had not reduced the oxygenation levels.
"Unfortunately, a fire ignited in the man's airway, and he sustained burns to the side of his face and shoulder and was transferred to the ICU," the statement from the office of the Health and Disability Commissioner said.
"This event caused significant challenges for the man and his family and impacted the quality of life in his remaining years."
The man died last year of laryngeal cancer.
The Commissioner's decision
Deputy Health and Disability Commissioner Carolyn Cooper released her decision on the surgical fire today.
The surgeon was found to have breached the Code of Health and Disability Services Consumers' Rights.
She said that "all precautions were taken during surgery" and "the surgeon diligently applied the appropriate risk management strategies", but they "did not apply the same precautions during the use of monopolar suction diathermy in a high oxygen environment".
Cooper was also concerned that the surgeon had not adequately communicated with the anaesthetic team.
She found the surgeon in breach of Right 4(1) of the Code. This gives consumers the right to services of an appropriate standard.
If the surgeon had explicitly communicated their plan to use diathermy, the risk of a fire could have been reduced, Cooper said.
"I also accept that it was the surgeon's intention to improve the patient's quality of life, and that he did not intend to cause him any harm.
"I also note that the surgeon has made several changes to his practice since events," she added.
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