A woman expecting a routine hysterectomy found herself waking up to a different reality that she had undergone treatment with mesh for a prolapse instead.

It would then be four months until she was granted a follow-up with the surgeon to find out what operation had been performed on her.

While the woman and surgeon’s version of events varied greatly deputy Health and Disciplinary Commissioner, Rose Wall has ruled the surgeon was “entirely inappropriate” in changing operative plans on a woman already prepped for surgery

Ms A’s ordeal began on June 14, 2013, when she sought medical advice for pelvic organ prolapse and was referred to Dr B, a consultant obstetrician and gynaecologist at a public hospital, by her general practitioner.

On November 18, 2013, Ms A met with Dr B at the Women’s Health Department of a public hospital where he discussed various treatment options but recommended surgery of a hysterectomy with the plan outlined in a letter to Ms A’s GP.

Despite undergoing a consent process and signing a form agreeing to the proposed surgery, Ms A’s experience took a drastic turn on May 22, 2014, the scheduled day of her surgery.

Thinking she was going in for a hysterectomy, the plan deviated significantly from what was documented on the consent form.

Instead, Dr. B performed an anterior and posterior repair using surgical mesh, and a cystoscopy. No hysterectomy was conducted, a fact that wasn’t communicated effectively to Ms A before the surgery.

Despite Dr B’s assertion that Ms A was informed about the surgical approach, Ms A disputes this claim, stating that she did not consent to using mesh.

Ms A told the deputy commissioner the conversation about a possible change in surgery occurred in the pre-op room and left her feeling unprepared and anxious about the procedure.

“A few minutes before going into the theatre, Dr B arrived and informed me she may perform a different procedure and would have a better idea once she had started the surgery. I did not comprehend that I may not have a hysterectomy... I had no time to focus on anything other than having a hysterectomy,” she said in a decision released today.

“I would never have consented to it if I had been given the chance. No one other than myself or any other patient should have the right to make a life-changing decision for themselves, not a surgeon by themselves.

“No way did I consent to leaving my uterus in place or having mesh used in the surgery. So when Dr B offered a hysterectomy in 2013, there was no way I’d change from that original consent. Many of my friends had spoken about life being so much better after hysterectomy and that was what I wanted,” she said.

After surgery, Ms A told a doctor on the ward she had a hysterectomy, to which he checked the notes and advised her she would need a follow-up appointment with Dr B to get the information.

Dr B did not see Ms A before discharge and it would be four months before she was able to ask him what he did to her.

By this time, she was experiencing pain in her hip.

“I had a lot of pain in my right hip at that time and was using a walking stick. That pain was difficult to manage. I wanted to ask Dr about the surgery, what Dr B did to me and why Dr B did it, but there was no opportunity due to the interaction between them and my hip pain,” she said.

For the next five years, Ms A had multiple opinions from various healthcare professionals with differing opinions and discrepancies in the documented procedure.

In 2021, Ms A underwent a full hysterectomy and removal of the mesh and by 2022 reported feeling “very well”.

Ms A complained the surgery was performed without her informed consent. Photo / Office of the Health and Disability Commissioner

Health New Zealand Te Whatu Ora and Dr B issued an apology to Ms A, however the matter was recently heard before the deputy commissioner to determine what penalty should be imposed.

Wall found Ms A did not provide informed consent and the failure to follow up within the required six weeks was a concern.

“Having considered the evidence available, on balance, I find that Ms A did not consent to having no hysterectomy on 22 May 2014. While ‘vaginal hysterectomy’ has been crossed out on the operation data form, it has not been crossed out on the consent form, or on the pre-operative checklist form,” Wall said in her decision.

Wall found the lack of post-operative information fell at the feet of Te Whatu Ora and it was ultimately their responsibility.

“The doctor on the ward took no action when she became aware that Ms A did not have a clear understanding of the surgery that had been performed. I would have expected the doctor to have followed up on this promptly to ensure that Dr B was made aware of Ms A’s confusion about the procedure.

“Because multiple staff members (the doctor on the ward and the other hospital staff) had the opportunity to ensure that Ms A’s concerns following the surgery were addressed promptly but did not do so, in my view, this deficiency in the follow-up care was a service delivery failure and responsibility rests with Te Whatu Ora.”

Te Whatu Ora has since updated its Informed Consent Policy, which was implemented in 2023, and said its current Informed Consent Policy is ‘substantially more thorough’ than the policy that was in place at the time of the events.

Wall recommended that Dr B, should he return to New Zealand to practice, undertake training in ensuring all treatment options are discussed clearly with patients and documented on consent forms.

Shannon Pitman is a Whangārei based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/ Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.