The Health and Disability Commissioner has found both Health NZ and a senior interventional neuroradiologist breached the Code of Health and Disability Services Consumers’ Rights over the death of a 51-year-old woman who deteriorated and died hours after an endovascular procedure in May 2019.

The woman, identified as Ms A, had infective endocarditis and required urgent valve surgery. Scans identified a likely mycotic aneurysm in her brain, and a multi-disciplinary team agreed to treat it first by endovascular embolisation. During that procedure, the lead operator, Dr C, caused an iatrogenic vessel injury that was not recognised at the time. Ms A was managed conservatively and kept on heparin with cardiac surgery planned, but she suffered an intracranial haemorrhage six hours later and died.

A subsequent Systems Analysis Review and an external independent peer review commissioned by Health NZ found multiple system and clinical shortcomings:

• No clear process for managing complications during angiography and no structured post-procedure briefing or team handover to ICU
• Conflicting and inaccessible post-angiography monitoring guidance, leading to less frequent neurological observations than intended
• Loose-leaf clinical notes held outside the official record and ambiguous documentation that underplayed the significance of the injury
• A departmental culture in which staff reported they did not feel able to challenge the lead operator’s decisions

The external reviewers also raised concerns about Dr C’s practice on the day: the microcatheter was left too long near the embolic agent, counter-traction was insufficient when force was applied to remove it, and the procedure was unnecessarily complicated given monoplane imaging. They said he did not seek available help from colleagues present, underplayed the severity of the injury to others, did not perform on-table or early post-procedural imaging to assess bleeding, and continued heparin despite a high risk of haemorrhage. The reviewers recommended Dr C should not act as sole or primary operator unless in a well-supported environment with at least two experienced colleagues, and that the hospital install a biplane angiography system.

Deputy Commissioner Dr Vanessa Caldwell found Health NZ breached Right 4(1) for failing to ensure care was provided with reasonable care and skill, citing multiple systemic failures in guidance, handover, documentation and monitoring. She also issued adverse comment on the environment that left clinicians feeling unable to speak up, and on the organisation’s responsibility to staff the service safely.

Dr C was found to have breached Right 4(1) for the care provided and Right 4(2) for failing to meet professional standards, including not seeking assistance when complications arose, inaccurate and incomplete records that minimised the injury, and inadequate handover to ICU. The decision referenced the Royal Australasian College of Surgeons’ Code of Conduct requiring surgeons to involve other health professionals where this benefits the patient.

Health NZ told HDC it accepts the findings and apologised to the family. Since the event it has:

• Installed a biplane angiography machine (July 2022)
• Introduced structured pre- and post-procedure briefings and refined handover between Interventional Radiology and ICU
• Consolidated post-angiography monitoring guidance into a single, accessible document
• Implemented “Speaking Up for Safety” training and team communication sessions
• Brought in external mentorship and longer supervision for new interventional neuroradiologists, and appointed a dedicated service manager

Dr C has not undertaken endovascular neuro-interventional procedures since 2019 and accepts the findings. The Deputy Commissioner recommended written apologies, reporting back on debrief processes and checklists, and using an anonymised report as a training case. Should Dr C return to practice, the decision recommends further teamwork and communication training; any return to endovascular work would include refresher training and mentoring.

The HDC will provide the report to the Coroner and the Medical Council. An anonymised version will be published on the HDC website. Ms A’s partner, Ms B, supported the investigation and said she hopes the decision prevents others experiencing the same.