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Patient suffers voice problems after consenting to surgery while affected by sedation

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A kapa haka enthusiast says she lost her mana after suffering ongoing voice problems from surgery she agreed to while under sedation. Photo / 123RF

A passionate kapa haka performer who has ongoing voice problems from surgery she consented to while under sedation, says she has lost her mana.

The woman was treated at a public hospital in 2019 and 2020 by an ear, nose, and throat specialist and head and neck surgeon after she was diagnosed with cancer in the thyroid gland in late December 2018.

There was suspicion the cancer had spread to her lymph glands. She had a nodule in her chest, but the precise nature of it was unclear.

Her case was discussed at a multi-disciplinary team meeting in January 2019, during which the team reviewed the results of CT and ultrasound scans, as well as a pathology report.

This showed she had a 20mm lesion on her right thyroid lobe that was a papillary thyroid carcinoma and a multinodular goitre on her left thyroid lobe, which extended into her upper chest.

The team proposed a surgical treatment plan comprising a total thyroidectomy [removal of the entire thyroid gland] and removal of lymph nodes from the neck.

Further investigation and referral to the Cardiothoracic Department was recommended regarding the mass in her chest.

The surgeon, who was not present at the team meeting because he was on leave, removed the woman’s thyroid gland and performed the central neck dissection in April.

However it was discovered there was no cancer in the woman’s lymph nodes, and she believes she underwent unnecessary surgery, a decision by the Health and Disability Commissioner (HDC) said.

She also has ongoing complications, particularly relating to her use of her voice.

The patient made a complaint to the HDC about the services provided by the surgeon at a district health board, now Te Whatu Ora Health New Zealand.

The investigation found the patient went to the hospital to have a biopsy of the mass in her chest, and another to diagnose different types of lung disorders, including inflammation, infections, or cancer on February 28, 2019.

She was given sedation before the procedures and the consent form specifically states patients must not make critical decisions for 12 hours after the sedation.

After the procedures the patient met with the surgeon, who she advised of the procedures, and claims she does not remember what was discussed.

The doctor told the HDC they discussed the need to remove the entire thyroid gland because of the confirmed cancer in one lobe and the enlarged multinodular lobe on the other side.

They also discussed the fact her case was complicated by her having a mass in her chest.

While the surgeon could not recall everything he told the woman, he would have advised her thyroid cancer was primarily treated with surgery, and it was intended the thyroidectomy and neck dissection would remove the cancer and achieve a cure.

He would also have advised the patient that not proceeding with surgery would pose a real risk of the cancer growing and spreading, he said.

The surgeon told the HDC he discussed the potential complications associated with both procedures, including the risk of injury to the nerves supplying the larynx and the four glands that control calcium metabolism.

He said he explained that damage to the nerves supplying the larynx could cause vocal cord paralysis, resulting in temporary or permanent hoarseness.

She signed the consent form which listed risks of “bleeding, infection, scar, hypocalcemia, recurrent nerve injury-hoarseness, further treatment, lifelong thyroid hormone replacement”.

The patient said she explained she was a performer and her voice, particularly her upper register, was an important part of her life.

She said that she would not have consented to the surgery if she had not been sedated.

The woman believes her concerns were not addressed in a culturally appropriate manner, in that any loss of her voice would potentially impact her mana within her kapa haka group.

She considers the surgeon underappreciated the issues.

HDC deputy Dr Vanessa Caldwell, in her report released today, expressed sympathy to the woman for the effect this has had on her life.

“It is clear the woman’s voice is of considerable importance to her, particularly her ability to participate in kapa haka, and she reports it has affected her mana,” Caldwell said.

“Her vocal difficulties have caused her significant distress.”

Caldwell found the surgeon breached the Code of Health and Disability Services Consumers’ Rights Code for discussing treatment options with a patient while she was affected by sedation.

She was also critical of the ENT specialist’s insufficient record-keeping during a specific consultation with the patient.

The surgeon acknowledged while the consent documentation was completed by the registrar, there was a lack of detailed documentation recording the risks that he discussed with the patient and the unique importance of her voice to her, both professionally and culturally.

He stated: “With the benefit of hindsight, I accept that this is the case and regret my contribution to this lack of documentation”.

Caldwell acknowledged the woman’s case was complex, with her care involving various services and clinicians at the then DHB.

“I remind the treating team, including the multi-disciplinary team, of the importance of taking a holistic view of a patient’s needs in their deliberations.

“For the woman in this case, this involved taking into account the personal significance of the use of her voice.

“The concerns were over the nature of possibly very advanced cancer, and appropriate attention was focused on achieving the best possible oncological outcome.”

She recommended Te Whatu Ora review the thyroid multi-disciplinary documentation with a view to including specific comments about an individual patient’s voice requirements, and audit a selection of the surgeon’s clinical records to assess compliance with the Medical Council of New Zealand guideline on maintaining patient records.

Caldwell also encouraged the surgeon to participate in the restorative process and after conclusion, if still requested by the woman, provide a written apology to her.

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