Failures in the post-surgical care of a woman - 19HDC02347

In a report released today, Deputy Health and Disability Commissioner Carolyn Cooper has found Health New Zealand Te Whatu Ora breached the Code of Health and Disability Services Consumers’ Rights (the Code) for inadequate care provided to a woman undergoing an outpatient elective procedure to remove an ampullary adenocarcinoma.

A duodenal perforation occurred during surgery and the patient, aged in her 70s, was admitted to hospital, where she received non-surgical treatment.

Over the course of her admission, the woman's condition deteriorated and she developed sepsis. Urgent surgery was performed but she did not recover.

The referral letter to the Coroner stated that the cause of death was sepsis secondary to the duodenal perforation.