Pre- and post-surgery management: HDC Case

Posted by dashboard at May 4, 2020 2:39 pm Blog
Pre- and post-surgery management: HDC Case

On 20 February 2018, the Health and Disability Commissioner (HDC) found that a DHB failed to provide services to Mr A with reasonable care and skill, and breached Right (4)(1) of the Code of Health & Disability Services Consumers’ Rights.

Below we provide a summary of case 15HDC00850, regarding the management of a patient before and after surgery. More information can be found on the HDC website.

Summary of the case

A 74 year old man was scheduled for total knee joint replacement. He had comorbidities including obesity and high blood pressure. He was reviewed by an RMO in a pre-assessment clinic prior to surgery.

The man was prescribed slow-release morphine and gabapentin as preoperative medications. Following surgery, which was uneventful, he was prescribed slow-release and immediate-release morphine, and other pain relief medications to manage his postoperative pain.

Once he was transferred to the surgical ward there was evidence of his condition deteriorating. However this was not acted upon, and his analgesia regimen was not reviewed in light of the deterioration.

The man was found unresponsive on the ward and was unable to be resuscitated.

HDC findings

It was held the service provided by the DHB was suboptimal in the following ways:


  1. The system for the preoperative assessment of the man’s risk, particularly of his risk during the postoperative period was inadequate.
  2. The man’s postoperative analgesia regimen was not reviewed in light of his particular circumstances.
  3. Nursing staff failed to assess and monitor the man regularly. Thus his deteriorating condition was not recognised and no contact was made with a senior member of the team to review the man.


Accordingly the DHB failed to provide services with reasonable care and skill and breached Right 4(1).

HDC Recommendations

The Commissioner recommended the DHB:


  1. Provide training to medical staff on the surgical ward regarding the use of opiates in the context of patients with obstructive sleep apnoea and/or renal impairment.
  2. Consider reviewing its streaming processes for preoperative anaesthetic assessment in light of the expert advisor’s comment that some non-anaesthetists may not be able to recognise a difficult airway accurately.
  3. Provide nursing staff on the surgical ward with refresher training on the use of the AED.


Preoperative anaesthetic assessment

The HDC and its experts noted:


  1. In this case there was a departure from ANZCA Standards.
  2. Pre-operative assessment and classification was undertaken by a non-anaesthetist RMO and was inadequate. The anaesthetist said no communication was made with him in advance regarding this patient’s risks, resulting in lack of planning/preparation to adapt care to the specific needs of this patient.
  3. The risk factors: morbid obesity; high blood pressure; COPD; Type 2 diabetes; previous myocardial infarction; and osteoarthritis were not recorded formally through an appropriate rating. The classification risks were underestimated. This had the potential to impact on Mr A’s care throughout his patient journey.
  4. Given Mr A’s risk factors including morbid obesity and observations suggesting a likely difficult airway with resultant high potential for sleep apnoea and hypoxic episodes postoperatively he should have been seen by a consultant anaesthetist before the day of surgery and possibly admitted the night before surgery, where sleep apnoea episodes could have been observed independently of the additional effects of surgery and analgesic opioid effects. Cardiac assessment should also have included chest x-ray and echocardiogram.


Care in this case was ‘usual care’ unmodified for this patient’s significant risks from co-morbidities. Mr A would have been best managed in a HDU with closer monitoring and observations. This required making arrangements in advance.

To improve outcomes there is a difficult balance needed between providing adequate pain relief to prevent complications associated with severe pain and to encourage early mobility, and the side-effects of medications.

There was a failure to review Mr A’s post-operative analgesia regimen. The use of standard pain relief programmes used in many hospitals in NZ after total joint replacement was bold in this case. As a general rule, older and obese patients need considerable scaling down of opiate doses. A one size fits all approach is not appropriate. In the light of Mr A’s deterioration opioids and NSAIDS should have been stopped or reduced once AKI (Acute Kidney Injury) was detected.

Nurses failed to assess and monitor Mr A regularly as should have occurred during the first 48 hours following joint replacement, and to appreciate that Mr A’s overall clinical status was deteriorating with significant departures from admission baselines and this should have triggered review.


  1. There was inadequate monitoring and recording of vital signs.
  2. There was inadequate monitoring and recording of fluid balance. The fluid balance chart was not maintained and Mr A did not receive the three litres of IV fluids charted post operatively on Day 1.
  3. Serum biochemistry results, low blood pressure, poor oxygenation, and increased respiratory rate readings required actions such as commencement of oxygen therapy, increased monitoring and communication with the surgical team for medical review.


GCS (Glasgow Coma Scale) is not a reliable measure for detecting respiratory depression. EWS (Early Warning Score) and ALERT (Acute Life-Threatening Events Recognition and Treatment) are important tools but in this case Mr A’s clinical deterioration should have triggered review in any event.

Consultants and registrars need to provide clinical oversight and leadership and should always review all assessment and observation charts including fluid balance chart and drug charts during ward rounds.



NZMPI is here to advise you in situations like the above. If you have any concerns, please get in touch with us to access our team of medicolegal experts. Whatever the outcome, we’ll guide you through the process.