Health professionals must provide adequate information and obtain informed consent before undertaking procedures

The importance of health professionals providing adequate information and obtaining informed consent from patients before undertaking surgical procedures was highlighted in a decision published by Deputy Health and Disability Commissioner Carolyn Cooper.

In her decision Ms Cooper found a surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide information to a woman about the possibility of the suprapubic catheter (SPC) placement, the associated risks of this, and obtaining her informed consent, should this procedure be necessary.

A woman, aged in her seventies at the time of the events, attended the district health board (now Te Whatu Ora - Health New Zealand) in 2017 for a planned procedure.

The woman underwent a urethrocystoscopy to investigate symptoms of recurring UTIs, bleeding, urinary frequency, and pain. During the procedure, in view of the severity of the woman’s bleeding and the surgeon’s findings, a catheter was inserted.

The woman was discharged home, but within 24 hours of being discharged she presented to the Emergency Department (ED) with abdominal pain, and was treated and discharged home. The following day she deteriorated again, and was admitted to ICU but, sadly, she died of septicaemia and bleeding complications.

Ms Cooper considered expert advice, that "this was a complex case with clinical risks, and in placing the suprapubic catheter, it would seem the surgeon believed he was acting in the woman’s best interests".

"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," says Ms Cooper.

"Given the risks associated with this procedure, it was important to obtain her informed consent, particularly in the woman’s circumstances where the risks were heightened in light of her medical history.

"By failing to discuss with the woman the risks associated with the placement of an SPC, she was not in a position to make an informed choice about her treatment," says Ms Cooper.

Ms Cooper recommended that the surgeon provide a written apology to the family, provide evidence to HDC that he has a system in place for ensuring that all treatment plans and their associated risks are discussed clearly with patients and documented on consent forms or clinic letters, and reflect on how he can improve his informed consent processes. She also recommended that the ED doctor provide a written apology to the woman’s family and arrange for a peer-reviewed audit of his documentation.

Ms Cooper further recommended Te Whatu Ora provide an update on its development of a regional electronic clinical record and standardisation of ED discharge summaries, its development of a policy regarding the return of recently discharged patients, and feedback on the support it is providing to its emergency medicine registrars and consultants to utilise bedside ultrasound in the ED.

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. This will assist with continuity of care for patients, and provide guidance to staff on the management of acute symptoms," says Ms Cooper.