Return of body parts after surgery

This report relates to the failure to return a patient’s tonsils following surgery at a public hospital.

On admission, the day-surgery nurse documented on the Preoperative Checklist (MR12) form the woman’s request to have her tonsils returned, and highlighted the request. The woman’s request was also noted by a trainee anaesthetic technician who was under the supervision of a registered anaesthetic technician.

The hospital’s process is that during “time out”, the circulating nurse holds up the Consent Form for the surgeon to read, and each member of the team is asked whether there are any issues that need to be addressed. No issues were raised during “time out” regarding the return of the tonsils, and there was no space on the Consent Form to record a patient’s wishes regarding the return of tissue.

The surgery took place without incident, and the woman was transferred to the recovery area. When she asked about the return of her tonsils, the tissue could not be found, despite a thorough search.

Findings

Right 7(9) of the Code provides that every consumer has the right to make a decision about the return or disposal of any body parts or bodily substances that are removed or obtained in the course of a healthcare procedure. The Deputy Commissioner acknowledged the significant personal and cultural importance of the matter for the woman, and considered that her wishes should have been respected. Accordingly, the Deputy Commissioner found that Southern District Health Board (DHB) breached Right 7(9) of the Code.

The woman’s request to have her body parts returned was a patient-specific concern that should have been communicated to the circulating nurse, and also identified during theatre “time out” as part of the surgical safety checklist process. The surgical team’s failure to communicate and cooperate effectively that day was found to have been a breach of Right 4(5) of the Code.

Recommendations

The Deputy Commissioner recommended that Southern DHB:

Revise its policy concerning patient requests for the return of body parts, to reduce the reliance on staff to pass on the information.

Review its admission process to ensure that patients who wish to have body parts returned have that request brought to the attention of the surgeon prior to surgery.

Undertake an audit of the use of Southern DHB’s surgical safety checklist at the hospital.

Read the full decision here