A partially tetraplegic man spent two months in an intensive care unit with bowel obstruction after a surgeon "mistakenly" formed a stoma at the wrong end of his bowel.
The Health and Disability Commissioner (HDC) has found the consultant general surgeon breached the Code of Health and Disability Services Consumers' Rights in the care of the man.
In a statement released from the HDC on Monday, Deputy Health and Disability Commissioner Dr Vanessa Cadwell found the surgeon performed a laparoscopic and colostomy incorrectly.
In 2020, the man fractured his spine and became partially tetraplegic (a form of paralysis affecting both the arms and legs), which resulted in difficulties with his bowel care.
On December 16, 2020, a surgeon at a private hospital performed a laparoscopic end-colostomy procedure – the surgical formation of an artificial anus, by connecting the colon to an opening in the abdominal wall.
However, during the operation the surgeon mistakenly formed the stoma at the wrong end of the bowel, the report stated.
A wrong-end colostomy occurs when the segment of the bowel used to form the stoma is not identified accurately, and the faecal matter is retained in the bowel rather than being collected in the colostomy bag outside the abdomen, HDC reported.
According to the independent advisor consulted during this investigation, the formation of an end colostomy in patients with bowel dysfunction after spinal injury is a well-recognised procedure, however, wrong end stoma formation is a significant technical error.
"I believe that formation of an end colostomy with the distal limb, resulting in large bowel obstruction should be considered a significant departure from accepted standard of care," Cadwell said.
Soon after, an attempt to insert a nasogastric tube was unsuccessful, and the man vomited and aspirated, leading to cardiorespiratory arrest.
He required 66 days of treatment in the intensive care unit
Dr Caldwell found the surgeon breached Right 4(1) of the Code for not providing services with reasonable care and skill.
"Following the surgery in a private hospital, the man was then admitted to a public hospital after developing post-operative complications," she said.
While Dr Caldwell noted there were delays in the follow-up treatment she was not critical of this, as the issues were multi-factorial, including that wrong end stoma is rare.
The surgeon had provided the man and his family with a written apology.
According to Caldwell, he had also taken a "number" of actions to improve his practice, including converting to open surgery rather than laparoscopic surgery, if there is any doubt about the correct end of the colon being made into a stoma, and "remaining vigilant for the possibility" of wrong end colostomy, among others.
The private hospital also made several changes to practice.
