Craniotomy in wrong location

Health and Disability Commissioner Anthony Hill today released a report finding a neurosurgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for performing surgery in the wrong place.

A man had neurosurgery to remove cancer in his brain. The surgical site was identified using a guidance machine and markings on the man’s skin. Once the initial incision was made, it became apparent that the guidance machine was inaccurate and the incision had not been made in the correct location. The skin markings had washed off and could not be used as a guide.

The neurosurgeon extended the bone opening into what he thought would be the correct area. However, it became apparent that the opening had been made in the wrong place of the man’s skull at which point the operation was discontinued. Further attempts to remove the tumour were considered to be too risky.

Anthony Hill accepted clinical advice that while any neurosurgeon could make this error it was still unacceptable. There were known risks with this complex surgery but Mr Hill considered that the neurosurgeon should have undertaken further checks and challenged his own assumptions about the correct location before extending the incision and found the neurosurgeon had breached the Code.

"Taking the time to undertake any checks available to ascertain that the surgeon is in the right place before proceeding with such surgery is paramount," Mr Hill said.

Anthony Hill recommended that the neurosurgeon apologise to the man’s family and that the DHB use his report for educating the neurosurgical community and considering ways to limit this happening again.

The full report for case 16HDC01498 is available on the HDC website.