Op found in ‘excruciating pain’

‘‘During surgery, the woman’s condition deteriorated, and she was transferred to ICU postoperatively,’’ the report finds.

At one point, the woman was found by a doctor in ‘‘excruciating pain’’ during her wait for surgery.

Former commissioner Anthony Hill identified a number of failures in the services provided by the DHB, including inadequate communication and handover between nursing staff; inadequate monitoring of the woman while waiting for theatre; and inadequate policies and procedures relating to after-hours acute surgery and handover of care between the ward and theatre staff.

‘‘It is extremely concerning that despite the nature of [the woman’s] condition, which required regular monitoring, no one staff member took steps to monitor [the woman], check whether she needed any pain relief or had any other needs, or follow up with her surgical team,’’ Hill said.

Hill also stated that it was his expectation that when staff transfer the care of a patient to another clinician, a complete handover should occur, particularly where regular monitoring of a patient was so important.

The report recommended the DHB audit patient waiting times for acute surgery on the weekend, and the monitoring of patients while awaiting surgery. He recommended the DHB provide an update in relation to its review of surgical policies, and provide a written apology to the woman.

‘‘It is extremely concerning that . . . no one staff member took steps to monitor [the woman], check whether she needed any pain relief or had any other needs, or follow up with her surgical team.’’

Anthony Hill