Watchdog finds staff felt unable to challenge senior doctor before patient's death after brain procedure
Health New Zealand has been found in breach of patient safety standards after an investigation into the death of a 51‑year‑old woman exposed a culture where clinicians felt unable to speak up to a "burnt out" senior specialist.
The Deputy Health and Disability Commissioner (HDC) Vanessa Caldwell ruled that both Health NZ and interventional neuroradiologist Dr C failed to provide services with reasonable care and skill in the lead‑up to the woman's death following endovascular surgery in May 2019.
The woman, referred to as Ms A, died after a complication during an endovascular procedure to treat an infected brain aneurysm that had arisen in the context of severe heart disease and infective endocarditis. She later suffered a catastrophic brain haemorrhage in intensive care and could not be saved.
'Staff felt unable to speak up'
The HDC was critical of several instances where the hospital's culture affected the woman's care.
One colleague told investigators that, although scrubbed in as an assisting INR, they were not involved in catheter manipulation, dynamic discussion or decision-making as Dr C was very used to working by himself.
In another instance, the anaesthetic registrar recalled becoming concerned when another INR, Dr G, entered the room to "offer a second opinion" and asked, "Are you sure you want to do it like that?"
According to evidence before the HDC, Dr G believed a serious vessel injury had occurred, but his concerns did not translate into a clear, collective decision to change course.
The HDC's Systems Analysis Review (SAR) and an external independent review further painted a stark picture of the working environment in the interventional neuroradiology (INR) unit.
Health NZ told the Commissioner that "the dynamic of the team was such that no staff member felt empowered to speak up to [Dr C]".
Staff interviewed for the SAR said "they did not always feel able to speak up directly to other staff within the department when they were concerned about a safety issue."
"Staff described a culture of a lack of trust and confidence that they would be heard, or their concerns acted upon," the review read, as quoted by the commissioner's findings.
Multiple clinicians also reported that Dr C tended to "persevere despite recommendations from other INRs," and that this behaviour had normalised silent compliance.
Caldwell concluded that the hospital environment "did not make for a safe environment for staff working with Dr C and/or his patients."
"In my view, it is important for staff to work in an environment in which they can speak up, especially where this concerns a patient's safety," Caldwell said.
"I am critical that the environment was such that clinicians felt unable to speak up to senior management at this hospital to enable this to happen," she added.
A 'burnt out' sole specialist
The decision also highlights the pressures on Dr C, who for months had effectively carried the hospital's endovascular service alone.
Dr C told the Commissioner he had been "the only INR at the hospital up until early 2019" and described himself as "burnt out."
Health NZ acknowledged that his workload was "significant at the time of the event."
"In my view, Health NZ had an organisational responsibility to staff its service safely," Caldwell said.
However, she found that burnout and resource constraints did not excuse Dr C's conduct in theatre or afterwards.
Despite recognising he had not encountered such difficulties and complications previously, Dr C did not actively seek help from his newer INR colleagues when a catheter‑related vessel dissection occurred.
He later acknowledged he "may have had an unconscious bias against colleagues due to their relative lack of experience," which played a role in his willingness to take advice from them.
The Deputy Commissioner found this directly conflicted with the Royal Australasian College of Surgeons' Code of Conduct, which requires surgeons to "seek the involvement of other health care professionals or more experienced colleagues if this will benefit the patient."
Breaches and consequences
Caldwell found that Health NZ breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights for multiple systemic failures, including the absence of clear guidelines for managing complications, lack of formal pre‑ and post‑procedure briefings, fragmented documentation, and inadequate post‑angiography monitoring.
Dr C was found in breach of both Right 4(1) and Right 4(2). The decision cites his technical errors, failure to seek or accept collegial input, the inappropriate sarcastic remark "What dissection?" when questioned about the injury, poor documentation, and incomplete handover, all falling short of professional standards.
Dr C has not performed endovascular neuro‑interventional procedures since 2019 and has voluntarily limited his practice. The Medical Council now restricts his vocational scope to diagnostic and general interventional radiology.
Reforms and apologies
In response, Health NZ has installed a bi‑plane angiography machine, strengthened team handover and debriefing processes, introduced "Speaking Up for Safety" training, and changed post‑angiography monitoring protocols.
An experienced INR from another district has been contracted to mentor staff, and new INRs undergo extended supervised practice.
Health NZ has welcomed the HDC's decision and said it hopes the outcome may offer some closure and reassurance to Ms A's whānau.
"We remain deeply sorry that this event occurred and for the distress it has caused," it said.
Dr C also accepted the HDC's findings, recommendations, and follow-up actions. He also wished to extend his "sincere condolences" to the family of the victim.
