A young woman sent home in a taxi had bowel fluid leaking from an abdominal wound, prompting the health watchdog to criticise her surgeon.
Health and Disability Commissioner Anthony Hill today released a report into the incident, in which he said the unnamed surgeon failed to provide enough care for a woman when she developed complications after an operation to repair a hernia.
Her situation was made even worse due to a critical medical machine breaking down over a public holiday weekend.
The patient, aged in her late 20s, saw the consultant in 2013 due to a discharge which had developed following an earlier Caesarean section.
She had surgery to repair the hernia but the surgeon had problems with tissue adhesions.
Those difficulties were not recorded by the surgeon, and nor did he review the woman's full clinical history, which would have shown the patient was born with a condition which needed significant abdominal surgery.
A Friday morning ward round which would have checked on her progress did not go ahead because it was a public holiday, the report said.
As the woman's post-operative progress declined over the weekend, a second surgeon became suspicious of an infection and ordered a CT scan.
However, the scanner had broken down and an urgent ultrasound was carried out instead.
The woman started to respond well to antibiotics and fluids in the intensive care unit after that check, and was sent back to the ward.
She then went back under the care of the first surgeon who, despite hearing the woman's complaints of abdominal pain and faecal ooze from her wound, discharged her from hospital and sent her home.
The woman was sent home in a taxi and said it was a painful trip, during which bowel fluid came out of her wound.
She eventually had to go back into hospital for further surgery.
"The first surgeon's pre-operative review of the woman was substandard, as he did not review her full relevant clinical history," Mr Hill said.
"It was also not appropriate for the surgeon to discharge the woman following her first admission when she had an appearance bowel fluid from her wound."
Mr Hill's report also criticised the unnamed district health board (DHB) for not carrying over its weekend care plan to public holidays.
"The woman's handover on Friday was affected, and was a contributing factor in sub-optimal co-operation and continuity of services."
Dr Peter Johnston, who advised Mr Hill during the investigation, said the patient suffered more than she needed to.
"I think [the woman] has had a greater degree of suffering than necessary in her post-operative course due to failure to adequately record the operative findings and being allowed to go home in the presence of a newly apparent discharge of bowel content from her wound," Dr Johnston said.
The patient complained to the DHB before going to the Health and Disability Commissioner.
"In her complaint to the DHB, the woman was told the DHB regretted not having been able to access her childhood surgical notes before her surgery but that having them would not have altered this being a technically difficult procedure and would not have helped to do things differently," the report said.
The surgeon added that his work was hampered by the break down of the CT scanner, which he expected would have been repaired promptly.
The surgeon no longer works in New Zealand but the Medical Council has been asked to review his right to practise in New Zealand, should he reapply to work in operating theatres here again.