Health board and surgeon apologise
An elderly man caught fire mid-surgery at Wairarapa Hospital, leaving him with third degree burns around his knee and needing skin grafts.
The hospital had “failed to provide appropriate care” to the patient and breached the agency’s code of rights Health and Disability Commissioner Anthony Hill found in his report, released on Monday.
The incident happened during knee surgery at the hospital in September 2017.
An orthopaedic surgeon had applied an alcohol-based solution to the edge of the man’s wound to prevent infection.
Without waiting for the alcohol to dry the surgeon then began diathermy, a technique which produces heat through applying electric currents to the body.
The alcohol caught fire, burning him until the surgeon put it out with water.
A week after the surgery, the man was discharged from hospital – at the time it wasn’t known how bad the burns were.
About two weeks after the surgery, it became clear to the doctors that the man had been left with third degree burns, he was referred to the burns unit for surgery and skin grafting.
In the report, the surgeon said he had been using the solution during joint replacement surgery for about a year with no complications.
“I did not appreciate the fire hazard with this routine, and neither did anyone else, until we did have a fire following a spark from the diathermy, and [the patient’s] leg was burnt.
“To [the patient], I can only repeat that I am very sorry that he experienced such a serious complication.”
Hill said the DHB had also failed to have an appropriate fire hazard policy for operating theatres.
The commissioner recommended the DHB and the surgeon provided a written apology to the man and confirmed the implementation of its new policy forbidding the use of alcohol-based solution until diathermy had been disabled.
It was also recommended the DHB prepared a fire hazard policy, audited its compliance with the existing guideline, and arranged training for its staff on fire hazards.
A further recommendation was that the surgeon should undertake further training about fire hazards in operating theatres.
Wairarapa DHB said it had “apologised unreservedly for the injuries the patient sustained, and for the resulting treatment and rehabilitation endured”.
“The DHB takes full responsibility for what occurred and immediately made significant changes to practice, policy and training in order to ensure it will not happen again.”
It had also developed a fire hazard policy and had completed training for its staff on fire hazards.
- If you would like to lodge a complaint with the Disability Commissioner, contact 0800 11 22 33 or email firstname.lastname@example.org.