Taranaki Base Hospital. Photo: Google Maps
A woman suffered significant, painful complications from a vaginal surgery for close to five years before another surgery to fix the problems was performed.
In a report released on Monday, deputy health and disability commissioner Rose Wall found Taranaki District Health Board's post-surgery care was inadequate, and breached the Health and Disability Services Consumers' Rights code for post-operative management.
The woman had complications soon after vaginal mesh tape sling surgery to treat stress incontinence in 2016.
She went back to Taranaki Base Hospital six weeks after surgery in pain and haemorrhaging.
Despite that, the report said the woman experienced considerable delays in review, investigations, diagnosis and treatment.
"The nature of her complications and the ongoing profound imposition they have had on her day-to-day life over this extended period cannot be overstated," Wall said.
After several visits to the emergency department and years of back and forth with specialists, the woman finally received remedial treatment - another surgery - in 2021, after it was decided the sling was not in the right position.
Wall noted two large delays in the woman's care. Her specialist had concerns about her in August 2017, but she was not referred to urogynaecology services until October 2018. She then was not seen until August 2019.
The first delay was attributed to the retirement of a specialist and his subsequent return to practice, resulting in a hiatus in the woman's care, which Wall labelled a "systemic" issue with Te Whatu Ora.
"If the specialist retired, they needed to ensure that appropriate systems were in place to transfer the woman's care to another specialist to action any plans in a timely manner."
But Wall could not determine the cause of the second delay between the woman's referral and appointment.
"Previously, this office has raised concern about failures by public health services to action referrals and manage follow-up in a timely manner," Wall said.
"As stated in those cases, it is the responsibility of healthcare organisations to ensure robust systems are in place to minimise the risk of errors occurring in the referral process and in arranging important follow-up."
It was also found the woman was not properly informed of the risks of her initial procedure.
While she was given a leaflet outlining potential complications, it warranted a verbal discussion allow her to consider the complications in more detail.
"Unfortunately the verbal discussions do not appear to have specifically highlighted some significant risks including the common risk of mesh exposure and the uncommon but potentially devastating risk of urethral injury," she said.
"Common and significant risks should be discussed verbally with the patient. The purpose of an information leaflet is to serve as an adjunct to these discussions."
Both the specialist and Te Whatu Ora should provide a written apology to the woman for the deficiencies in care, Wall recommended.
Since the events, Te Whatu Ora has set up monthly multi-disciplinary meetings between the urology and gynaecology teams to discuss and review all women referred with urinary incontinence issues.
They have also recently established the New Zealand Female Pelvic Mesh service to support and care for women harmed by pelvic surgical mesh.