A gynaecologist and an obstetrics and gynaecology trainee have been censured after performing a procedure on a woman without local anaesthetic causing her "the most incredibly horrific pain".
In a report released on Monday, the Health and Disability Commissioner Morag McDowell found the senior doctor and trainee breached the Code of Health and Disability Services Consumers' Rights (the Code) for the care they provided to the woman during the procedure.
The woman, who was in her twenties at the time, was referred to as Ms C in the report. She received the results of a cervical smear test that showed abnormal squamous cells and on March 6, 2019, she underwent a procedure at Greenlane Hospital to remove abnormal cells from her cervix following results from a smear test.
The LLETZ procedure employed to remove the abnormal cells was commenced without administering local anaesthetic, causing the woman significant pain.
McDowell found the gynaecologist, who was in the role of supervisor and most senior doctor involved in the procedure, and the trainee/registrar who performed the procedure, breached the Code for failing to provide services with reasonable care and skill Tautikanga.
"The standard of care applicable is the care and skill that an ordinarily careful peer of the clinicians involved would exercise under similar circumstances," said McDowell.
"Most clinicians would have ensured that local anaesthetic was applied prior to commencing the LLETZ procedure."
In her complaint to HDC, Ms C said when the procedure began she was "filled with the most incredibly horrific pain" and was screaming as she felt the electrically surging wire "cut through" her cervix.
She said she was then told by one of the staff that they "had to get through that loop before they could address the pain", and that she was scolded for shaking and was held down in an attempt to keep her still. She said that at no point during the procedure was she apologised to or told that a mistake had been made.
Ms C told HDC that she also experienced a burning sensation during the procedure, but when she raised this, the clinicians did not respond to her concerns. She said she suffered burns to her vagina and upper thighs from the iodine.
The trainee meanwhile told HDC she began the procedure by performing a "touch test" - which involves touching the loop briefly to the cervix wall to ensure that the electrical current was working.
She stated that this test caused Ms C a significant amount of pain, causing her to yell out, and it was then realised the anaesthetic had not been administered before the test.
She told HDC the LLETZ loop was removed immediately without reactivation, and all staff apologised to Ms C.
The trainee then swapped places with the senior doctor who called for and administered the local anaesthetic.
The trainee told HDC that she does not remember any of the staff holding Ms C still or down or scolding her for moving.
She added she does not recall Ms C mentioning any burning sensation, such as from the iodine, apart from "when the loop was applied to the unanaesthetised cervix".
McDowell said she is satisfied the issues outlined in the case were primarily the responsibility of the individual clinicians involved. However, she was critical of Health New Zealand/Te Whatu Ora Te Toka Tumai Auckland because it failed to upload Ms C's consent form to her file.
The Commissioner also said a more empathetic approach was warranted by Health New Zealand after this adverse event, including personal contact to assist in the woman's recovery.
McDowell was unable to make a finding over differing recollections around whether the registrar and gynaecologist had notified the woman of their respective roles as trainee and supervisor when seeking consent for the procedure.
However, she took the opportunity to remind both doctors and Health New Zealand of the need, when undertaking procedures, to clearly identify clinicians and their roles to the patient, and to ensure that consent is obtained in circumstances where teaching is taking place.
Since the event Health New Zealand, the gynaecologist and registrar have made changes to their practice.
In addition, McDowell outlined further recommendations in her report, including for the gynaecologist and the registrar to provide formal written apologies to the woman.
McDowell also recommended that Health New Zealand consider implementing as a requirement the practice of using saline wash at the end of all gynaecological procedures that use iodine and consider updating its adverse event policy to require a follow-up to patients who have suffered an adverse event.
