19 July 2024

Surgeon failed to inform woman of knee surgery results, says HDC

A surgeon breached the Code of Health and Disability Services Consumers’ Rights (the Code) after deficiencies in communication during both preoperative and postoperative consultations relating to knee surgery.

The woman, who experienced knee pain from a fall, presented to an orthopaedic surgeon for review. An MRI showed a tear in the band of cartilage in the outer side of the knee and the surgeon recommended surgery to remove any damaged tissue.

During surgery, the surgeon discovered the tear was stable and so did not remove any of the damaged tissue, but he did find and remove a small unstable tear on the inner side of the joint. He also found a moderate degree of arthritis in the knee, but neither this discovery, nor the tissue removal, were communicated to the woman after surgery.

At a post-operative consultation, the woman complained the surgery had not improved her pain and believed the surgeon dismissed her concerns without providing adequate details about the surgery.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the surgeon did not undertake an adequate physical examination of the woman, or obtain a basic medical history from her, prior to surgery. The surgeon also failed to consider and discuss the other potential causes of the pain in the woman’s knee, including the evolving osteoarthritis, as indicated by the MRI report.

Dr Caldwell found the surgeon breached Right 4(1) of the Code for failing to provide services with reasonable care and skill during the preoperative consultation. She also criticised the surgeon for failing to inform the woman adequately about any conservative treatment options and the risks and likelihoods of the surgery being successful.

As the woman did not receive all necessary information about the surgery and her condition to enable her to make an informed decision, Dr Caldwell found the surgeon breached Right 6(1) (which gives every consumer the right to information a reasonable consumer would expect to receive) and Right 7(1) (which states services may be provided only if the consumer makes an informed choice and gives informed consent). She also found the surgeon breached Right 6(1) of the Code as he did not adequately inform the woman of the results of the surgery.

Dr Caldwell recommended the surgeon provide a written apology to the woman for the deficiencies in care identified and reflect on the deficiencies in communication during both the preoperative and postoperative consultations. She also recommended he undertake an audit of documentation and clinical records to assess whether changes made in documentation had been followed and identify remedial actions as needed.

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