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A patient who stopped breathing during a colonoscopy may have been sedated differently if the surgeon had checked his medical history, Health and Disability Commissioner Morag McDowell says.
The man in his 60s was intubated after he stopped breathing during a colonoscopy, despite having previously had a lung removed.
He died after a perforation to his colon.
McDowell found Te Whatu Ora Nelson Marlborough failed to ensure communication between clinicians and the surgeon should have checked the man's clinical notes.
The man had several co-morbidities which included a history of lung cancer requiring a pneumonectomy.
There was no nurse-to-nurse handover from the ward to the endoscopy suite, despite this being policy, McDowell found.
The endoscopy team was unaware of the man's prior pneumonectomy until difficulties arose and the man was administered an inappropriate induction dose of sedation through endoscopist-led sedation, she said.
"[The doctor], as the clinician performing the colonoscopy procedure on Day 22, had ultimate responsibility for ensuring that [the man's] relevant clinical history was known prior to the procedure. I acknowledge [the doctor's] comments that [the man] was an unexpected addition to the afternoon scope list. However, I also agree with [the independent general surgeon advising McDowell]... that by commencing with a booked procedure, [the doctor's] actions indicated that after taking everything into consideration, [the doctor] was comfortable that the procedure was appropriate.
"[The doctor] failed to review [the man's] clinical notes, and proceeded with the colonoscopy procedure without all the relevant information, which led to the administration of an inappropriate induction dose of sedation to [the man] through endoscopist-led sedation. I have been guided by my independent advisor in reaching these conclusions."
Te Whatu Ora had conducted an internal review and updated its processes, but both it and the surgeon should apologise to the man's family, McDowell said.
"[NMDHB] has conducted its own investigation and review of practice (at my request) and we have made substantive changes to our processes, particularly around communication, handover and documentation. I am confident that these would minimise a similar event occurring in the future. Once again I would like to pass on my sincere condolences to the family," the surgeon told the commission.
