The Health and Disability Commissioner is recommending the case of a man who had the wrong part of his skull cut into during neurosurgery be used to educate neurosurgeons around the country on the risk.
Commissioner Anthony Hill has also recommended the neurosurgeon in question provide a written apology to the family of the man, who has since died from cancer.
The commissioner heard the man underwent neurosurgery at a public hospital for the removal of a brain tumour.
The neurosurgeon determined the positioning of the surgery using a guidance machine, and he and a registrar marked on the man's skin where the incision would be.
Once the initial incision was made, however, it became apparent that the guidance machine was inaccurate.
The neurosurgeon extended the bone opening into what he thought was the correct area. However, it became apparent that the opening had been made in the wrong place of the man's skull.
The operation was then discontinued and further attempts to remove the tumour were considered to be too risky.
The commissioner said once the neurosurgeon realised that the craniotomy was in the wrong location, he should have undertaken further checks before deciding to proceed.
Mr Hill therefore considered that the neurosurgeon not provide services to the man with reasonable care and skill and, accordingly, breached the Code of Health and Disability Services Consumers’ Rights.
Mr Hill was also critical that the neurosurgeon did not arrange for a follow-up consultation with the man after the surgery.
The commissioner obtained expert advice from neurosurgeon Dr Agadha Wickremesekera.
"Reading the operative note the standard of care for this process was satisfactory however inadvertently the error was made hence there is a departure from the accepted standards of neurosurgical outcomes," Dr Wickremesekera stated.
"Such an error can be made infrequently. As in this case all neurosurgeons use anatomical landmarks as well as the assistance of the neuronavigation," he said.
Dr Wickremesekera said the scalp markings should have been undertaken with an indelible marker so that they do not get washed off.
"I agree that the error is entirely preventable as opposed to a complication such as a post-operative haemorrhage several hours after surgery which is entirely out of one’s control."
The commissioner recommended that the DHB shared services group use his report as a case study to educate the neurosurgery community on the risk of incorrect craniotomy placement, and to assess further ways to prevent such an event occurring again.
It was also recommended that the neurosurgeon provide a written apology to the man's family.
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