The surgeon said the woman wanted her nasal airway improved and that they had discussed additional surgery.

But, her version was that he “convinced” her to undergo the surgery, despite the fact she didn’t want her nasal airway improved and didn’t initiate the conversation.

She considered he had “upsold” her the treatment following the original purpose of her visit, to have the tumour removed.

The surgeon said he had discussed the risk of additional surgery, and performed it in June 2020, undertaking procedures to address sinus issues, improve airflow, drainage and ventilation.

Concerns raised

Within two days, the woman raised concerns with the surgeon, telling him her left nostril collapsed when she inhaled deeply. He told her to continue rinsing it and to add a steroid spray to the rinse.

After three weeks, she visited the surgeon and was advised that “the nose has settled down beautifully”.

There was no correspondence in clinical notes about the visit or that she had raised concerns about her collapsing nostril.

Again, she outlined concerns about the nostril at a third post-operative appointment. She said the doctor then became defensive, agreeing that the left nostril was collapsing but said “that this was still a good outcome”.

His consultation notes show at that point, for the first time, the woman’s complaint was documented.

The surgeon noted near full healing, adding the tumour couldn’t be ruled out, but he felt that the analysis was overly cautious and the nasal passage was entirely normal.

He did touch on the issue of what intervention might be required to correct the collapse, discussing surgery.

At that point, the decision said he acknowledged in his consultation letter that the patient had “certainly expressed dissatisfaction with a collapsing nostril with forced inspiration”.

The woman said there was then a heated disagreement and that she was advised by the doctor that he no longer wished to treat her and asked her to leave.

She was, according to her recollection, “castigated” by the receptionist for her apparent rudeness, and left.

She said she emailed the clinic with a complaint on the same day, telling the Health and Disability Commissioner that she had not received a response from the doctor or the clinic.

Doctor at odds with patient concerns

The doctor said the woman’s explanation of the final appointment was “wholly unacceptable” and that ”something certainly didn’t feel right about the way (she) engaged and what was being explained to her”.

He said the collapse was caused by forced breathing and that normal breathing post-surgery may take up to 12 months.

He said the woman was “overly dramatic” and became upset when video images showed that the nasal cavity was not out of place.

The surgeon said she was not interested in viewing the video footage or formulating a treatment plan.

He said he knew she could be “very unpleasant and aggressive” and, as he didn’t wish to get into an argument with her, he “stood up and terminated the consultation”.

He told the commissioner he wrote a “full report” to her GP on the same day and advised her to seek the guidance of another ear, nose and throat surgeon.

‘Missed opportunity’ for resolution

Deputy Health and Disability Commissioner Vanessa Caldwell said the doctor breached part of the Code of Health and Disability Services Consumers’ Rights as he did not provide the woman with a written acknowledgement of her complaint within five working days and missed an opportunity to resolve it.

The doctor could have communicated clearly in writing, outlining the reasons why he did not accept the complaint and any proposed actions he intended to take, and any appeal procedure that he had in place.

She was also critical of him for ending the doctor–patient relationship “to avoid argument” saying it wasn’t a sufficient enough reason to do so, nor was the woman making a complaint about him.

“Consumers are entitled to ask further questions about the outcome of surgery and to make complaints under the Code.

“Even if the relationship was deemed ‘irretrievable’, as (the doctor) submits, this should have been managed in a professional manner.”

Caldwell said the lack of information provided about the risk of a collapse was a mild departure from accepted practice and the doctor failed to explain why additional surgery was necessary.

While she was unable to make a finding about the doctor’s diagnosis due to a difference in clinical opinion, Caldwell said the woman “trusted” his judgment as an “expert”.

“In my view, this illustrates an imbalance of power within the doctor–patient relationship, where consumers may feel unable to challenge a doctor’s recommendation or make decisions based on trust (as opposed to an informed choice based on knowledge about their health status and alternative treatment options).”

It was noted the doctor had however taken the matter “very seriously” and made changes to his practice, taking part in a consent development forum, data collection processes, formalised complaint procedures, a review of doctor-patient relationship guidelines and an increase in staff, including a plastic surgeon who specialises in nasal surgery.

The doctor was told to apologise to the patient and undertake an audit of compliance with the complaints procedure.

Al Williams is an Open Justice reporter for the New Zealand Herald, based in Christchurch. He has worked in daily and community titles in New Zealand and overseas for the last 16 years. Most recently he was editor of the Hauraki-Coromandel Post, based in Whangamatā. He was previously deputy editor of the Cook Islands News.