A young Jehovah's Witness died on the operating table following a communication bungle in which her surgeon was not told she would refuse a blood transfusion.
The medical watchdog has revealed details in the case of the 31-year-old South Islander who was admitted to hospital for a routine surgical procedure for gallstones.
However, the surgeon operating on her was not aware of the woman's stance until after the operation, when she started haemorrhaging blood.
He demanded a blood transfusion that would save her life but she refused and died a short time later.
Health and Disability Commissioner Anthony Hill released a report into the woman's care today, criticising the surgeon, the anaesthetist and Nelson Marlborough District Health Board for failing the patient.
The case details state the woman was admitted to a hospital in 2010 for laparoscopic cholecystectomy, a routine operation to remove the gallbladder deemed straight-forward and low risk.
Four days earlier the woman's parents had presented hospital staff with a letter written and signed by their daughter ordering that she receive no blood transfusions.
It stated: "I direct that no transfusions of whole blood, red cells, white cells, platelets or plasma be given to me under any circumstances, even if health-care providers believe that such are necessary to preserve my life."
"I refuse to predonate and store my blood for later transfusion."
The anaesthetist was aware of her position but did not tell the surgeon, who failed to read the information in the woman's case file ahead of the operation.
During the procedure, due to difficulties with access and visibility, the surgeon converted to open surgery but after it was over, the woman's condition deteriorated.
The specialist ordered a blood transfusion, discovering first-hand from the sedated woman that she would not accept blood.
She died a short time later.
Mr Hill was highly critical of communication between the specialists, saying "common sense, let alone good practice, demands that this information is known to all senior members of the operating team."
"In this case it was not."
He said: "Teams and systems should do better than this".
The two specialists should have discussed the situation ahead of the operation, "and in time for other plans and preparations to be made, should these have been necessary".
The DHB was told to review its pre-admission process and all parties were ordered to write letters of apology to the woman's family.
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