A woman who had surgery to relieve chronic back pain suffered a severe injury during the procedure, leaving her dependent on a wheelchair.
Earlier that day at Hawke’s Bay Hospital, staff mistakenly prepared her sister for surgery and took her to the anaesthetic room.
Staff caught the error in time and operated on the correct patient. However, the surgery damaged the woman’s spinal cord, causing complete loss of motor and sensory function in her legs.
She now has no movement or sensation below the L2/L3 area, except for nerve pain in her left leg. She also suffers impaired bowel and bladder function and uses a wheelchair.
The woman, in her sixties, sustained the injury during surgery at the Hastings hospital in 2020.
The Health and Disability Commissioner’s (HDC) report, released today, anonymized the identities of both the patient and the orthopaedic surgeon. They are referred to as Mrs A and Dr B.
Both Dr B and Health NZ Te Matau a Māui Hawke’s Bay, which manages the hospital, breached patient rights.
The report notes that the woman’s sister was mistakenly prepared for surgery. While at the hospital for back pain, she alerted the surgeon before the operation began.
“Dr B did not detect the error until he discussed the incision. Mrs A’s sister then pointed out that staff had taken the wrong family member for surgery,” Deputy Health and Disability Commissioner Vanessa Caldwell said.
Persistent Back Pain Leads to Surgery
Mrs A had back surgery in 2016 for a herniated disc but continued to experience significant pain. In 2019, she consulted Dr B about relieving pressure on her spinal nerves.
The planned procedure was an OLIF (Oblique Lateral Interbody Fusion). This technique minimizes muscle cutting and uses a single port to access the disc space, insert bone graft material, and fuse lumbar vertebrae. “Cages” held the graft in place after disc removal.
An external review found multiple technical errors contributed to the injury. Staff used imaging insufficiently, positioned the patient and instruments incorrectly, and misinterpreted neural monitoring data. Caldwell accepted these findings.
While no single factor caused the injury, the combination compounded the outcome, leading to the devastating result.
Surgical Technique Found Inadequate
Caldwell concluded, “Dr B’s surgical technique was inadequate and below the expected standard of care.”
Dr B, a newly qualified consultant, performed complex surgery never done before at Hawke’s Bay Hospital. He lacked the credentials for OLIF procedures and did not seek a support surgeon despite recommendations.
“Dr B failed to obtain sufficiently current information to make a reasonable decision to perform this complex surgery. He did not follow credentialing policies or the hospital’s OLIF procedures,” Caldwell said.
The HDC concluded that Dr B did not provide care to Mrs A with reasonable skill, breaching the Code of Health and Disability Consumers’ Rights. Health NZ also breached the code due to poor credentialing, failure to provide a support surgeon, and noncompliance with new procedure policies.
The HDC instructed Dr B and Health NZ to apologise to Mrs A. Sections of the report about Dr B have been referred to the Medical Council of New Zealand.
Mrs A’s family submitted an impact report detailing her ongoing pain and distress. They said Dr B told them a “blunt wedge” likely caused the injury, adding it “should not have been inserted into such a small gap.”
Rika Hentschel, Health NZ’s acting group director of operations for Hawke’s Bay, offered a “sincere and unreserved” apology.
“We regret the deficiencies in care that caused profound and irreversible damage, significantly affecting the patient’s quality of life,” Hentschel said. Health NZ Hawke’s Bay has implemented improvements to systems and policies following this catastrophic event.
“The number of patients harmed or distressed in our care is small, but we take each case seriously. We review incidents and make necessary changes to protect patients and staff,” Hentschel concluded.
Source: RNZ, Health and Disability Commissioner Report
