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Woman injured after surgeon 'did not remember' unique condition

December 5, 2022
3D illustration of kidneys in a body.

A surgeon failed to provide appropriate care to a patient after forgetting to read critical information ahead of surgery, the deputy Health and Disability Commissioner says.


The woman was receiving a hysterectomy surgery in July 2019 when her left ureter - a narrow tube that carries urine from the kidneys to the bladder - was inadvertently injured.

"I was never ever told [that I might get ureter damage] to one of my tubes because it was something I was terrified of. I've always known I had the duplex kidney and [it's] something I would have reconsidered because [I've] always been scared of the safety of surgery around it," the woman told the HDC.

She said the incident affected her loved ones, friendships, job, and in particular her mental well-being. The woman told the HDC she suffered severe pain for two months, thinking it was normal postoperative pain.

Deputy Health and Disability Commissioner Deborah James said the woman's surgeon did not read the clinical notes or the radiology report prior to the operation. He also forgot about the woman's unique condition of having two ureters draining from her left kidney into her bladder, instead of the usual one.

James found the surgeon breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights: the right to have services provided with reasonable care and skill.

"A surgeon needs to read the notes to the extent necessary to be satisfied that, as the operating surgeon, they have all of the information that they need to know," James said.

The surgeon told the HDC he deeply regretted he had caused an injury to his patient's ureter. He said it was "very disappointing" he did not follow his "usual routine" on the day of the surgery and review the pre-operative consultation note.

"This had specific information about the double ureters and I believe, if I had read this, it is possible the injury could have been prevented."

James recommended the surgeon provide a written apology to the woman and suggested the providers consider a restorative meeting.

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