Investigation 12HDC01488 – Death # 3 and Cover Up
The conspiracy to cover up fraud, obstruct justice and block a patient’s right to live. Death #3
Two years after a previous death in similar circumstances we are once again dealing with the same hospital, with the same surgeon and a second death – the patient bled to death from his open Cholecystectomy surgery procedure. This occurred with the same Health and Disability Commissioner (HDC) in charge and the same protections in place. Informed consent fraud took place, the HDC covered it up yet again and in the process breached the rights in the ‘Code of Health and Disability Services Consumers’ Rights’ (Code of Rights).
What follows next was truly shocking. The HDC took extraordinary steps to ensure that the police would not prosecute and that charges would never eventuate or be laid against the parties responsible. Specifically, this gave yet another ‘free pass’ to those responsible and ensured that the Police concluded their investigation into the death of a patient at Wairau Hospital in Blenheim without sufficient evidence to prosecute or lay charges.
Recap : Previously, in the first HDC death investigation a ‘free pass’ was given, allowing informed consent fraud to occur. The non-disclosure of risk, side effects and the lack of provision of alternative treatment options are all mandatory and required in order for consent to be obtained legally. This non-disclosure was accepted by the HDC as ok.
Recap : Previously, in an unpublished ruling, just prior to this death, the HDC took extraordinary steps to whitewash consumer complaints about the method that New Zealand surgeons obtained consent for cholecystectomies. The complaints made the point that consent was obtained illegally through deceptive and fraudulent means. The HDC was strongly advised it would breach the Code of Health and Disability Services Consumers’ Rights and would be held accountable for personal damages such as loss of income and loss of life expectancy for every cholecystectomy carried out in New Zealand, if they failed to investigate informed consent fraud as mandated by the HDC Act. The outcome was as follows, the HDC chose to ignore its own non-surgical recommendation that confirmed that New Zealand surgeons were deliberately lying to Health Consumers and the HDC about chronic side effect outcomes of cholecystectomies and alternative non-surgical treatment options.
2. Take Home Points
- This unfortunate death may never have happened if the HDC had not given a mandate for New Zealand surgeons to withhold informed consent.
- Every patient consent for cholecystectomies in NZ obtained by deception and concealment, breaching the legally enforceable Code of Rights.
- This confirms the much advised, yet unwritten HDC policy that no surgeon will ever see the inside of a courtroom for breaching the legally enforceable Code of Rights.
- Any police changes laid in relation to a criminal offence, such as manslaughter, as a result of preventable patient deaths or medical malpractice fraud, is considered a hindrance to the HDC’s perceived application of the legally enforceable Code of Rights. Instead this attitude reinforces their unwritten police of ‘learning not lynching’ of medical practitioners and protecting them rather than holding them accountable. This equates to legalised fraud by the HDC.
- The HDC are directly accountable and an accessory to the fact in another patient death.
(Note: the intended purpose of this article is to highlight another example of the breach of rights 6(2) and 7(1) of the Code, possibly resulting in the death of yet another patient. However, when examining these investigation notes in conjunction with HDC00531, (first death), it became apparent that natural justice was being obstructed by the Health and Disability Commission again. Expanded commentary is provided in the hope that one day an open and transparent police investigation might occur and justice will be served, so that the victims’ families and those affected can move forward with their lives.)
3. What Happened
An elderly man, who died on an operating table, was not told that his surgeon was working under restricted duties in a voluntary agreement with the New Zealand Medical Council. The surgeon in question was instructed not to undertake laparoscopic cholecystectomies until the completion of a performance assessment committee review after several medical mishaps, including the laparoscopic cholecystectomy.
The surgeons recommended the removal of his gallbladder and a hernia repair operation. Because of his previous aneurism surgery, he would need an open cholecystectomy operation, which would be more significant than a laparoscopic approach because of his age and the trauma to his body.
Key Note: thus was never going to be a straightforward operation, higher risks were in place due to existing conditions.
There was no record of any information regarding available alternative options being provided. No disclosure was made to the patient of information pertaining to the fact that the surgeon had restrictions on his surgical practice.
An hour after the operation the patient’s blood pressure began to drop. An ultrasound scan showed internal bleeding. Parry decided to re-operate to control the bleeding. During surgery, another vein was damaged, causing further blood loss and the patient died.
4. Outcome from Police Investigation
The surgeon won’t be charged over the death of the patient:
- “Police have concluded an investigation into the death of a patient at Wairau Hospital in Blenheim and have decided not to lay charges.”
- ‘A coroner’s inquiry into the two deaths was put on hold in December 2012 when police launched their own investigation into one of the deaths, to determine whether there was any “liability or culpability”. The deaths, along with surgeries performed on three patient, also came under scrutiny during the police inquiry’
- “their investigation file had been independently reviewed by the Tasman Crown solicitor who concluded the evidence gathered did not reach the threshold for prosecution and no charges would be laid”
- “Police received information from the Nelson Marlborough and Canterbury district health boards, the Medical Council and the Health and Disability Commissioner. A surgeon in Hamilton also provided them with an independent report on operation”
- The matter had been referred to the coroner.
5. Outcome from the HDC Investigation
- The surgeon, by not providing information on restricted surgery practice – breaching Right 6(1)
- The surgeon’s decision to proceed with a full cholecystectomy meant that he did not provide services with reasonable care and skill (a subtotal cholecystectomy should have been performed) – breaching Right 4(1)
- The surgeon’s delay in re-operation was poorly managed and placed the patient at harm – breaching Right 4(4)
- The surgeon made a serious error in failing to provide services with reasonable care and skill to Mr A during the second surgery – breaching Right 4(1)
- The Nelson Marlborough DHB is responsible for the post-operation lack of critical thinking and proactivity of staff. The Nelson Marlborough DHB failed to provide services to Mr A in a manner that minimised the risk of harm and, accordingly, breached Right 4(4) of the Code.
Protection – Conspiracy to obstruct justice and a failure to identify patient Code of Rights breaches. What really happened?
According to the HDC’s detailed investigation, the only breach of common law identified was that when the surgeon obtained ‘legal consent’ to operate on the patient, the surgeon simply forgot to advise the patient of his restricted surgery practice from performing Laparoscopic Cholecystectomy procedures, due to the fact it was most likely not considered as a treatment option. When the surgeon obtained consent for Open Cholecystectomy surgery, he breached Right 6(1) ‘Every consumer has the right to the information that a reasonable consumer has’.
That is the entire result of the investigation that could lead to criminal charges ranging from ‘liability’ or ‘culpability’, to ‘manslaughter’, from any actions of gross negligence .There was no action taken by the HDC to refer this matter to the police. Quite simply, it was a ‘free pass’ and the surgeon forgot to advise this patient of his restricted practicing for performing Laparoscopic Cholecystectomy with a previous death and three major injuries within 12 months. And the fact this death occurred while waiting for a performance assessment by the Medical Council of New Zealand, the body able to terminate registration.
The HDC identified that there were no other breaches, by either the surgeon or the Nelson Marlborough DHB that would provide the police with the justification to lay criminal charges, as a result of their evidence gathering process. Although, it was referred to the Director of Proceedings in accordance with section 45(2)(f) of the Health and Disability Commissioner Act 1994 , no proceedings were taken whatsoever. The HDC had given a strong indication that this was a forgone conclusion when advising.
The HDC even went on to recommend, “In the event that Dr C returns to practice, he should just simply self-review his practice when operating on patients with severe co-morbidities” so as not to kill them. Essentially the HDC is saying to this particular surgeon and the local DHB it does not matter what you do, we have your back, keep practicing on patients for your learning and your own experience.
HDC protection continued:
Somehow the HDC failed to identify the following breach in this investigation:
About the same time of the police investigation and the subsequent HDC investigation, the HDC removed from publication an almost exact scenario investigation, which detailed that an elderly patient’s death that may not have occurred if informed consent had been provided. In this current investigation, no reference is made to this eerily similar scenario [HDC investigation #12hdc00779]. That investigation detailed the following breaches of the Code of Rights 6(1)(2), 7(1), and 4(2)). Reading this at face value indicates that the HDC gave a ‘free pass’ in this more serious investigation and covered up the findings.
HDC Compliant investigation # 12hdc00779 (see link provided)
“In the absences of any record documented evidence detailing whether the gallstone related pain he was experiencing, if any, was significant enough for him to undergo surgery in light of alternative management options, or the risks of surgery that were specific to him, including his increased risk of death”
- The surgeon failed to provide information that a reasonable consumer in his position would have needed to make an informed choice about treatment, breached Right 6(2) of the Code of Health and Disability Services Consumers’ Rights (the Code)
- The surgeon did not obtain informed consent for surgery from Mr A, and breached Right 7(1) of the Code.
- The surgeon demonstrated a lack of reasonable care and skill in deciding to perform surgery and approach to condition postoperatively was insufficiently cautionary, breached Right 4(1) of the Code
- In addition, [the surgeons] documentation fell below professional standards and, accordingly, surgeon breached Right 4(2) of the Code.5
- There was a lack of discernible leadership, coordination and critical thinking in the clinical team treating the patient postoperatively, and a lack of support offered by senior doctors to junior staff. This demonstrated a service level failure by DHB) to provide services with reasonable care and skill, and was a breach of Right 4(1) of the Code.
- Furthermore, there was a pattern of suboptimal documentation by clinical staff treating patient postoperatively. The Commissioner found that DHB failed to ensure that its staff met expected standards of documentation, and breached Right 4(2) of the Code.
And another HDC Compliant investigation #03HDC19128
However, the HDC did make reference to HDC Compliant #03HDC19128, an exact scenario investigation where a cholecystectomy health consumer complained about a surgeon, who withheld information about their surgery restriction for Laparoscopic Cholecystectomy and the patient would not have proceeded if they had been advised. Yet again, the open Cholecystectomy surgery recommendation was not fully accepted by expert option, indicating the patient was misled. It was found that the open Cholecystectomy should never have taken place but instead they should “treat this patient with antibiotics and let the whole thing settle”, and she would then be placed on the waiting list for a routine (Laparoscopic) cholecystectomy. That investigation detailed the Surgeon had breached Right 5 and 7.
The Code is based upon the central right of patients to be fully informed in order to make informed choices. Informed consent is a process that is embodied in three essential elements under the Code: effective communication (Right 5), provision of all necessary information (Right 6), and consent freely given by a competent consent (Right 7).
Right 6(1) gives every patient the right to information that a reasonable consumer, in that patient’s circumstances, would expect to receive. Right 6(1)(a) to (g) of the Code sets out specific types of information that a patient may expect to receive, including the right to information about the options available (Right 6(1)(b))
6. Further breaches strangely NOT identified by the HDC
1. Lack of clinical record notes documentation:
It was repeated in the HDC case notes that there was a lack of documentation to confirm alternative treatment options and risks presented to the patient. Should the fact of this admission to the police and past investigations have triggered a breach for the HDC Compliant investigation? # 12hdc00779: –
“[the surgeons] documentation fell below professional standards and, accordingly, surgeon breached Right 4(2) of the Code.”
2. Informed consent legal breach – No treatment side effects disclosed:
Doctors have a statutory obligation to abide by the Code of Health and Disability Services Consumers’ Rights (the Code). Under the Code every patient has the right to make an informed choice and to give informed consent
There is no evidence risks of the side effects likely to affect the quality of life of the patient were discussed in regards to the surgery. Furthermore, nothing was documented in the Nelson Marlborough DHB informed consent and patient handout out information guide. This is a breach of common law. Consent was not legally obtained and a criminal offence occurred.
|Post Cholecystectomy complications (side effects risks)
Bile Reflux, gastritis, pancreatitis, Irritable Bowel Syndrome and Sphincter of Oddi Dysfunction are just a few of the more common complications that can occur from 2 days to 25 years post gallbladder removal, all of which can reduce quality of life for a patients. This is because
Cholecystectomy is associated with several physiological changes in the upper gastrointestinal tract, which may account for the persistence of symptoms or the development of new symptoms after gallbladder removal. The cholecyst sphincter of Oddi reflex, cholecyst-antral reflex, and cholecyst-oesophagal reflexes are all disrupted and some local upper gastrointestinal hormonal changes also occur after cholecystectomy. Thus, there is an increased incidence of gastritis, alkaline duodene gastric reflux and gastro-oesophageal reflux after cholecystectomy, all of which may be the basis for postcholecystectomy symptoms.
Symptoms occur in about 5 to 40 per cent of patients who undergo cholecystectomy (up to 43% recorded in woman), and can be transient, persistent or lifelong. The chronic condition is diagnosed in approximately 10% of postcholecystectomy cases
(See appendices section for full details of side effects affecting quality of life)
3. Informed Consent legal breach- no treatment options disclosed
There is no evidence alternate treatment options were recorded as being discussed with the patient or documented in the Nelson Marlborough DHB informed consent, nor were they detailed in a patient informed consent handout out information guides. This is a breach of common law. Consent was not legally obtained and a criminal offence occurred. Indicating free pass given in this more serious outcome investigation
The surgeon is required by law to provide non-surgical treatment options during the informed consent process. The following question should be asked of the HDC: Why was Oral Dissolution Therapy not considered when gallstones were first identified in CBD and gallbladder? Or why was there not even a nutritional diet plan discussed to prevent things escalating further? There was a 4-month treatment window of opportunity before the surgery was carried out.
(See appendices section for alternate treatment options not presented)
(See appendices on a history of why surgeons lie in order to obtain consent)
As seen also in HDC investigation # HDC00531 (first death case notes) in breach of the Code, no treatment options are provided by the surgeon, as legally required. Nor was it disclosed to the patient of the direct risks of surgery such as bleeding or the resulting risk of a blood transfusion:
- The surgeon “advised (the HDC) that he recommended Ms A have a (laparoscopic) cholecystectomy “as the only proven and gold standard treatment of symptomatic gallstone disease”. He stated that other possible treatment options were not discussed as no other treatment is recommended in fit patients with symptomatic gallstones.
- No disclosure of risk of bleeding or risk of blood transfusion.
Fast forward to our current investigation, the case notes confirm details of the breach of Right 6(1)(b) and a lack of informed consent:
- “There is no further documentation of any other particular risks or options that were discussed with Mr A. Dr C stated to the Police that although he did not document the full discussion of the options and risks, he believes they were fully discussed”
- “There was no record of any information regarding the available alternative options having been provided”
It was stated to the Police that the surgeon in question advised Mr A that, in view of his age, an alternative treatment option was to do nothing further, in the hope that any further stones reaching the CBD would pass through the sphincterotomy, but there was a chance that acute cholecystitis could occur. Doing nothing and offering no alternative non-surgical treatment options could be considered as guaranteeing a further client for surgery and is a failure to provide a duty of care to the patient. This is a breach of Right 4(4), ‘Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of the consumer.’ Alternative treatment options could have included diet changes and bile salt dissolution.
(See appendices section for alternate treatment options not presented)
- “Dr C stated to the Police that he advised Mr A that, in view of his age, an alternative was to do nothing further in the hope that any further stones reaching the CBD would pass through the sphincterotomy, but there was a chance that acute cholecystitis and even acute cholangitis could occur.
Summary of breaches
Right to informed consent
Right 6(1)(b) Every patient have the right to the information that a reasonable consumer in his circumstances would expect to receive, including an explanation of the treatment options available and an assessment of the expected risks, side effects (affecting quality of life), benefits and costs of each option. Failing to disclose risks during the informed consent process breached Right 6(1)(b) of the Code of Health and Disability Services Consumers’ Rights (the Code).
Right 7(1) –Informed consent is obtained illegally, by fraud deception
Every consumer has the right to make an informed choice and give informed consent. Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent. Without this information, patients are denied that opportunity to legally give informed consent.
Right to services of an appropriate standard
Right 4 (4) Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of the consumer.
Informed consent fraud was not only protected by the HDC but a written ruling mandate was also provided:
|The HDC written mandate to defraud health consumers – (Investigation HDC6446 ruling outcome),
Under a signed off mandate by the HDC every health consumer consent obtained for cholecystectomy surgery carried out in New Zealand is obtained by deception and concealment, breaching the legally enforceable Code of Rights. This breaches common law and is a criminal offence.
The HDC reviewed and signed New Zealand surgeon’s gold standard patient information brochure about laparoscopic gallbladder surgery. Nowhere in the “Royal Australasian College of Surgeons (RACS) Brochure of Laparoscopic Gallbladder Surgery” is the word ‘death’ mentioned. Nor is there ANY alternative treatment options or side effects affecting quality of life considered. This can be considered a lack of critical information and paramount to obtaining informed consent through deception
Because of this, the HDC can be directly held accountable for blocking patients’ rights to make an informed consent decision. As a result, they are an accessory to the fact, in obtaining consent fraudulently through the means of deception and are also accountable for any resulting harm.
HDC:” I support the surgeon’s intention to provide patients with a copy of the newly published Royal Australasian College of Surgeons’ Patient Handout for Laparoscopic Cholecystectomy. In my opinion, it is likely that if the consumer had had access to this detailed information some of her (informed consent) concerns (about risks) may have been more swiftly alleviated.”
6. Should the Surgery Have even Taken Place?
As with the HDC Compliant investigation 12hdc00779 and 03HDC19128, the HDC investigation must consider if there is sufficient justification to carry out an Open Cholecystectomy surgery in an urgent manner, when a surgeon’s performance is under review by the NZMC. This was strangely not investigated in this case.
Case Notes: Exactly one month after undergoing a procedure known as an ERCP to remove two CBD stones, a patient was admitted to hospital with abdominal pain, vomiting, fever and rigours.
More about Gallstone Symptoms:
- Sudden and rapidly intensifying pain in the upper right portion of your abdomen
- Sudden and rapidly intensifying pain in the centre of your abdomen, just below your breastbone
- Back pain between your shoulder blades
- Pain in your right shoulder
- Nausea or vomiting
And from HDC own advisor prior to this investigation , Case # not published
“The majority of patients found to have incidental gallstones will remain asymptomatic. When symptoms occur, they are usually biliary colic rather than complications of gallstone disease. The cardinal symptom of gallstones is biliary colic. Biliary colic is a moderately severe crescendo type pain in the right upper quadrant radiating to the back and right shoulder, which may be accompanied by nausea. Despite its name, the pain is usually steady and not colicky. Pain may be brought on after ingestion of fatty foods. Gallstones are sometimes implicated as the source of symptoms in patients with dyspepsia. However, such an association should be made cautiously, since gallstones may silently coexist in patients with dyspepsia, and other causes of dyspepsia are more common.”
Dr David Maplesden, Medical Advisor, Health and Disability Commissioner
Nowhere in the investigation case notes is it mentioned that the patient was diagnosed as having gallbladder related symptoms. And as with the HDC Compliant investigation finding #12hdc00779 and # 03HDC19128, the surgery should not have taken place.
HDC Compliant investigation # 12hdc00779, ‘In absences of any record documented evidence detailing whether pain he was experiencing was gallstone related was significant enough for him to undergo surgery in light of alternative management options, or the risks of surgery that were specific to him, including his increased risk of death’ (resulting in death)
7. Freedom from Coercion, Exploitation
Alternative treatment management options were withheld and the patient was left with only two choices. The surgical option, an open cholecystectomy, or die from Sepsis:
- 1] Undergo Open Cholecystectomy surgery to treat symptoms of abdominal pain, vomiting, fever and rigours and present of gallstone seen in gallbladder, with higher risks due to a history of significant medical co-morbidities, which included an abdominal aortic aneurism repair.
- 2] Or do nothing, no alternative treatment options, and suffer and potentially die.
Case notes: The patient wanted to proceed with surgery rather than adopt a ‘wait and see’ approach, to reduce his on-going discomfort and to prevent further recurrent episodes of sepsis. Sepsis is a potentially life-threatening complication of an infection.
Question: Was sepsis a medical justification for gallbladder surgery?
The only treatment option presented to the patient is tantamount to a breach of the Code of Rights, including:
|Right 2, Right to freedom from discrimination, coercion, harassment, and exploitation. Every consumer has the right to be free from discrimination, coercion, harassment, and sexual, financial or other exploitation. (much valuable training experience)
Right 4 (4) every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer. (not end your life)
Note: New Zealand surgeons believe they are under the protection of the HDC and New Zealand’s unique laws covered by ACC (Accident Compensation Corporation). When a patient signs a surgeon’s consent form, that is completely absent of any disclosed long term side-effects; risks affecting quality of life, or risk of complications, or alternative treatment options; the patient has accepted a surgeon’s opinion to be true and honest and has received the required information to make an informed consent. Therefore, the surgeon cannot be held liable for any subsequent damage to the health of the patient or their resulting death. Malpractice lawsuits have effectively been blocked despite breaching common law – Consent was not legally obtained, a criminal offence.
This is regardless of the information given being void of any knowledge of alternative treatment options, or side effects listed that are potentially life long and/or chronic. As such, this withholding of information should be considered deceptive informed consent and even intent to commit likely harm for entrepreneurial gain on patients
Was the Nelson Marlborough DHB criminal liability or culpability covered up by under the protection of the HDC?
Can the Nelson-Marlborough DHB be he held criminally liable able as an employer for the death of two patients and a higher than normal injury rate? The answer is yes. After all, the Health and Disability Commissioner Act is supposed to be legally enforceable.
Employers are vicariously liable under Section 72(2) of the Health and Disability Commissioner Act 1994 (the Act) for any breach of the Code by an employee. Under Section 72(5) of the Act it is a defence for an employing authority to prove that it took such steps as were reasonably practicable to prevent the act or omission of employees that breached the Code. – (Source: Health and Disability Commissioner Act 1994)
More about the Law: A hospital employing surgeons has an obligation to maintain and monitor their competence, to protect patients. This duty is recognised by statute and the common law.
The Law – Employer responsibility
More about the Law: A hospital employing surgeons has an obligation to maintain and monitor their competence, to protect patients. This duty is recognised by statute and the common law.
Section 11(3) of the Health and Disability Services Act 1993 provided that it was an objective of every hospital and health service to exhibit a sense of social responsibility by having regard to the interests of the community in which it operates (section 11(3)(a)), and to uphold the ethical and quality standards generally expected of providers of health or disability services (section 11(3)(b)). The Health and Disability Services Act 1993 was repealed from 1 January 2001, and replaced by the New Zealand Public Health and Disability Act 2000 (the NZPHDA), which established District Health Boards. Section 23(1)(i) of the NZPHDA provides that for the purpose of pursuing its objectives, each District Health Board must, as one of its functions, monitor the delivery and performance of services by it and by persons engaged by it to provide or arrange for the provision of services. The NZPHDA also provides that it is an objective of every District Health Board to improve, promote, and protect the health of people and communities (section 22(1)(a)), to exhibit a sense of social responsibility by having regard to the interests of the people to whom it provides, or for whom it arranges the provision of, services (section 22(1)(g)), and to uphold the ethical and quality standards commonly expected of providers of services and of public sector organisations (section 22(1)(i)).
Criminal liability or culpability
Employers are vicariously liable under Section 72(2) of the Health and Disability Commissioner Act 1994 (the Act) for any breach of the Code by an employee. Under Section 72(5) of the Act it is a defence for an employing authority to prove that it took such steps as were reasonably practicable to prevent the act or omission of employees that breached the Code.
Both public and private hospitals are also subject to the duties imposed on health care providers by the Code of Health and Disability Services Consumers’ Rights, in particular, the duty to provide services with “reasonable care and skill” (Right 4(1)). The organisational duty of care and skill of a public hospital has been considered in several major Health and Disability Commissioner reports, including Southland District
Part II – Was the Police investigation compromised?
Recap: First, we need to understand the approach taken by the HDC towards enforcing health consumer rights and protecting against fraud, negligence and malpractice.
|HDC mandated protection against health consumers:
The Disability Commissioner Act came into force on 1 July 1996. The Code was supposed to give patients and healthcare consumers legally enforceable rights. It subjected all health practitioners and healthcare providers to a new set of legal duties when providing health services.
The Code of Rights became enforceable via the independent Health and Disability Commissioner (HDC), also known as the gatekeeper. As a result, 1996 was the last year for a conviction in New Zealand of a health practitioner for ‘medical manslaughter’. Medical disciplinary hearings had dropped from ninety to three, annually, by 2012. With the HDC in place, the ultimate utopia of protection for medical practitioners had been established. The legally enforced Code of Rights became nothing more than an ultimate protection scheme to ensure that doctors and health service providers would never see the inside of court room to face charges for manslaughter as a result of negligence or a failure to provide a duty of care to protect patients from harm, or even death. Medical fraud, even if it results in death, has effectively been decriminalised. Health providers have instead been provided with an ultimate clinical freedom to practice how they like on patents, without any consequences. As a result, health consumers are fair game for surgeons carrying out unnecessary procedures. The door has also been opened for health providers and surgeons to lie to patients in order to persuade consent from unsuspecting clients.
According to the publications, the HDC believe that any police investigation of a health provider, leading to criminal charges in the consumers fight for natural justice, or even misleading clients in criminal fraud, is some kind of public lynching of the ‘good doctor’.
The HDC has openly stated it is against any police investigation that leads to criminal charges and manslaughter resulting from gross negligence. It is viewed as nothing more than a hindrance to its perceived application of the legally enforceable Code of Rights. The HDC’s much lauded policy of ‘leaning, not lynching ‘AKA protecting, not holding medical practitioners accountable, is nothing more than the prevention of natural justice and is not in any way supported by the Health and Disability Commissioner Act. The HDC has even bragged that under its watch ‘protection’ many health practitioners who are ‘guilty’ of major failures in their care, causing a patient’s death, escape prosecution.
Every one (including HDC misusing using statutory powers) is liable to imprisonment for a term not exceeding 7 years who conspires to obstruct, prevent, pervert, or defeat the course of justice in New Zealand under Crimes Act 1961 No 43 (as at 28 September 2017),
Public Act 116 … www.legislation.govt.nz/act/public/1961/0043/latest/DLM329005.html
The Police investigation – Questions needed answering
The Police failed to find sufficient evidence to reach a threshold for medical malpractice or negligence and no charges were laid against any party. The Questions that need to be asked, concerning the police in their investigation, to consider the evidence and dismiss the case and determine no liability or culpability, are as follows:
Question 1: Was consent for treatment legally obtained?
In order for consent to be legally obtained, the following requirements need to be met under a legally enforceable Code of Health and Disability Services Consumers’ Rights (the Code): The following advice had to take place. An absence of such information would indicate fraud:
|Did the health service provider / surgeon:
And as such,
And did the HDC conceal these breaches in his investigation
Question 2a: Was consent obtained for Laparoscopic Cholecystectomy?
The son of the patient in question was told it would be a “straightforward keyhole surgery” and for some reason it switched to an open procedure, without consent being obtained by the patient.
A review of the patient’s records should show informed consent documentation. In this case, the surgeon failed to keep records up to date, so answering this question may not be possible.
Mr A’s son told HDC that he went to see his father the night before the operation. His father talked about having met with Dr C, and said he was having a gallbladder operation, and that it would be “straightforward keyhole surgery”. Mr A’s son does not recall his father saying anything about whether the surgery was the only option or one of several options, and said it was more a case of his father telling him that that was what was happening.
Question 2b: If surgical restrictions were in place for a Laparoscopic Cholecystectomy, why would the surgeon offer Laparoscopic Cholecystectomy as one of the two surgery treatment options?
The surgeon offered Open Cholecystectomy and Laparoscopic Cholecystectomy and then finally performed Open Cholecystectomy as the preferred method of treatment.
Question 3: Did the Nelson Marlborough DHB take reasonable steps? As follows:
“ reasonably practicable to prevent the act or omission of employees that breached the Code or covered up. Failing to do so would result in a justification for police criminal prosecution under the Health and Disability Commissioner Act 1994 where employers are vicariously liable under Section 72(2) steps as were reasonably practicable to prevent the act or omission of employees that breached the Cod”.
According to the HDC, yes, the Nelson Marlborough DHB did have processes in place and this was supported by the following protection from prosecution out clauses:
- HDC “unless there had been concerns raised about Dr C’s judgement and his performance of surgery other than laparoscopic cholecystectomies, NMDHB would have had no reason to expect that a senior, well trained surgeon would have issues with what is a very common operation. HDC went on to say “ Although I consider that the concerns with Dr C’s performance should have been seen as a warning signal, in all the circumstances, I do not consider that NMDHB breached the Code by allowing Dr C to continue performing surgery other than laparoscopic cholecystectomies”
- And HDC Advisor “the decision (by Nelson Marlborough DHB) to permit Dr C to perform an open cholecystectomy at the Hospital was appropriate, as experienced surgeons, anaesthetists, staff and resources were available, and the operation is performed regularly at the hospital”
Let’s view this from another perspective, which is 100% contradictory to the HDC’s ruling. They decided that no breach of the code took place, resulting in no culpability and the Nelson Marlborough DHB really did not breach Right 4(1) of the Code – not take adequate steps to respond to escalating concerns about competence . And the Nelson Marlborough DHB did not fail to take steps to prevent this serious event occurring. The steps taken were deemed to be reasonably practicable to prevent the act or omission of the employees that breached the Code. It is a good idea now to conduct a review of what happened:
1. Employee (surgeon) appeared to be operating with no supervision as stipulated by the Medical Council of New Zealand for registration and employment at Nelson Marlborough DHB. The employee was placed under conditions of a pending NZMC review, as such, operating without supervision would be a breach of the code:
“Requirements by Medical Council of New Zealand (MCNZ) for registration and employment at HDB. Specifically, employed with following requirements indicate ‘lesser experience ‘surgeon NOT a senior surgeon as advised to Police and HDC.
- “under the onsite supervision of consultant general surgeon Dr D”
- and “offsite supervision of a consultant general surgeon”
And given these serious events (1 x Patent death , 3 x serious bile duct injuries) occurring 12 months after commencing work with the Nelson Marlborough DHB, would it not have been prudent for the Nelson Marlborough DHB to ensure the requirements by Medical Council of New Zealand (MCNZ) for registration and employment at Nelson Marlborough DHB were stringently met? This reiterates the point that “supervision” of this surgeon was critical.
Evidence points to the fact that the Nelson Marlborough DHB was criminally culpable because the surgeon advised that he did not consult with his colleagues, let alone a supervisor put in place by the Nelson Marlborough DHB. As such, could this second death have been avoided if they strictly enforced the supervision requirements?
The surgeon: ‘expected the operation to be relatively uncomplicated, so he did not feel it warranted discussion with other colleagues’
2. Did the Nelson Marlborough DHB really have experienced surgeons in place to take over or remediate when difficulties arose? Bearing in mind it was a smaller hospital and 115km away from the nearest main centre hospital. As advised, “the decision (by Nelson Marlborough DHB) to permit Dr C to perform an open cholecystectomy at the Hospital was appropriate, as experienced surgeons, anaesthetists, staff and resources were available, and the operation is performed regularly at the hospital”. This is In direct contradiction with the evidence available:
- In the second surgery attempts to stop bleeding, both surgeons advised they were “Dr C stated that Dr D had never used the Rummel tourniquet technique previously either”
- Despite a ‘consulting surgeon participating in the surgery’ there is no evidence a more senior surgeon was available or took over and made the correct critical thinking decisions.
- “Dr C accepts that an injury to the portal vein occurred during the placement of the Rummel tourniquet, and that this was a surgical error on his part”
Given that a second occurrence of surgery restrictions was now in place, pending a review, should an Open Cholecystectomy procedure with higher risks have been allowed to proceed by the Nelson Marlborough DHB with alternative treatment options available?
The HDC found no breach in allowing the surgery to take place. All this was decided upon with no obvious senior skill set on site or available to take over and assist and make critical decisions.
If the surgery should not have taken place under the circumstances , then the Nelson Marlborough DHB should be held criminally liable for the patient’s death. This is confirmed by the outcome of the following ruling in similar circumstances:
Under the exact same circumstances, a surgeon waiting review with a string of lesser life terminating mistakes, (04hdc07920), the HDC slammed a DHB for not acting sooner or taking appropriate steps to address performance problems. The surgeon was allowed to carry out Open Cholecystectomy and caused injury. In this case, a more serious event has occurred and the patient has in fact died.
HDC Compliant investigation 04hdc07920: Here is the outcome from the similar cholecystectomy surgery mistakes:
HDC “The fact that the Medical Council is undertaking or has completed a competence review, or imposed a competence programme, does not detract from an employer’s obligation to ensure that a clinician is providing services of a safe and appropriate standard to patients. The employer’s obligation to assess its employee’s performance under the employment contract exists independently of the Medical Council competence review process. The DHB appeared to be aware of this obligation when it commenced a concurrent internal inquiry to assess the appropriate steps to address …. Patient safety and the organisation’s fulfilment of its responsibilities to the public.
HDC Compliant investigation outcome: “Hospital did not take adequate steps to respond to escalating concerns about competence, and breached Right 4(1) of the Code”
Given the response to this case it is remarkable that the HDC did not address this breach with the Nelson Marlborough DHB. Why not? Especially when the Police investigation needed supporting evidence?
3. The outcome of the HDC investigation was that the Nelson Marlborough DHB was required to implement the following procedural improvements, confirming that the Nelson Marlborough DHB really did not have the process in place (take steps) as were reasonably practicable to prevent the act or omission of employees . These failures would result in a justification for police criminal prosecution under the Health and Disability Commissioner Act 1994.
In total contradiction to the HDC ruling, these gaps in process confirm a likely breach of employer duties. To ensure steps were taken, as were reasonably practicable, in order to prevent the act or omission of employees that breached the Code. If they were really in place, the patient could well be alive today.
- HDC : To “Develop a process to ensure that complex patients are discussed by a multidisciplinary team prior to undergoing surgery.”
- HDC: To “Report on decision-making protocols relating to the transfer of complex patients to other hospitals.”
- HDC: To “Report on final decisions relating to surgical services and ICU at the Hospital, including staffing arrangements. This report is to include protocols relating to access to senior medical staff by less senior medical staff.
4. The acting surgeon, as an employee, obtained consent through deception, concealment of his restrictions and by using the hospital’s brochure and the informed consent form about the laparoscopic gallbladder. However, as reiterated several times these documents are completely void of side effects and alternative treatment options and as such breach the Code, Right 6(2). Quite clearly states that deception cannot be used to obtain consent. As such, consent was not legally obtained from the patient. The hospital seems to back the surgeon’s standard practice of offering no alternative treatment options whatsoever. More concerning, is that every consent obtained By Nelson Marlborough DHB is obtained illegally.
See link : More information about the fake informed consent documents omitting alternative treatment options and the risks of side-effects affecting the quality of life of patients that are not disclosed by the Nelson Marlborough DHB.
Question 4: Is there a civil conspiracy between the DHB and the HDC in place to obstruct justice?
During the course of the first HDC investigation over the death of a patient # HDC00531, the Nelson Marlborough DHB knew about two other serious injuries but never disclosed this to the HDC investigation. This is mentioned in the published investigation # HDC00531.
“In 2010, Dr C commenced employment at the Hospital. NMDHB advised that the first adverse incident relating to Dr C that came to its attention was the death of a patient in early 2011, owing to a postoperative haemorrhage following an open cholecystectomy that had been converted from a laparoscopic procedure. At the time of the internal investigation of that case, NMDHB became aware of two cases of common bile duct injury during laparoscopic cholecystectomies performed by Dr C, which had occurred in late 2010 and early 2011”
As it follows, the question needs to be asked by the police, if these serious injuries had been disclosed by the Nelson Marlborough DHB to the HDC in the first investigation, would this have influenced the first HDC investigation? Would the resulting outcome of a ‘free pass’ occurred, or, instead would there be a different ruling resulting in a stand down with significant retraining as seen with previous HDC investigation outcomes (i.e. 04hdc07920).
However, if the HDC was actually advised of the other serious injuries by the Nelson Marlborough DHB during the first investigation and choose to conceal them as not being relevant, then this could be construed as concealment and protection of the surgeon in order to give them a ‘free pass’. If so, then the HDC becomes an accessory to the fact and are culpable for the second death, by failing to investigate the case in a open and transparent manner.
Question 5: Was the police investigation setup to fail and/or obstructed?
Yes, the investigation was set up to fail. 3 of the 6 information gathering sources, Nelson Marlborough DHB, the Health and Disability Commissioner and the surgeoncould be held culpable is some manner. The other information gathering sources were the CDHB, the Medical Council and an Independent Surgeon Advisor.
Question 6: More specifically, was the police investigation setup to fail and/or obstructed due to their investigation requiring the gathering of information from the HDC?
Yes, given the HDC’s much publicised assurances given to doctors, DHB’s and the Government and their ‘learning not lynching’ policy. The HDC also have a strong dislike for doctors to see the inside of a court room or to legally enforce the HDC act as seen by previous investigation outcomes: Over 99% of health consumer complaints were never investigated and a majority were dismissed, A very small minority of complaints are formally investigated and research has further shown that relatively clinical misconduct charges against doctors are ever brought before the Health Practitioners Disciplinary Tribunal (HPDT), by the HDC.
And did the HDC give this surgeon a ‘free pass’ for breaches of the Code for this and the earlier deaths, in similar circumstances, hereby compromising the evidence gathering process?
- Government reveals HDC’s true set objectives which are : Quote for New Zealand Government in parliament, “the ability of the Health and Disability Commissioner to dismiss vexatious complaints will help to protect practitioners from having to go through unnecessary trauma and stress”
Health Practitioners Competence Assurance Bill, Health and Disability Commissioner Amendment Bill, Medicines Amendment Bill — Third Readings https://www.parliament.nz/en/pb/hansard-debates/rhr/document/47HansD_20030911_00000850/health-practitioners-competence-assurance-bill-health
- In a research article by Kim Davies. FEWER CHARGES ARE BEING LAID IN THE HEALTH PRACTITIONERS DISCIPLINARY TRIBUNAL: SHOULD WE BE CONCERNED, it is investigated whether the HDC’s approach of “learning not lynching, resolution not retribution” had shifted the balance too far towards the focus on rehabilitation of doctors at the expense of leaving clinically incompetent doctors in practice. The document summarised with the following, “In the author’s opinion, the Commissioner, the Director of Proceedings, the Medical Council and Professional Conduct Committees need to give serious consideration to whether the complaint system is becoming less patient focused through the laying of fewer clinical charges”
Kim Davies. FEWER CHARGES ARE BEING LAID IN THE HEALTH PRACTITIONERS DISCIPLINARY TRIBUNAL: SHOULD WE BE CONCERNED? http://www.nzlii.org/nz/journals/VUWLawRw/2015/49.pdf
Question 7: Why would a coroner’s inquiry into the second death have to be put on hold until the police completed their investigation?
Input from an independent coroner’s report is a vital component of evidence gathering and also the investigation process into a doctor’s competence, which is needed for the police to determine whether they should lay charges for prosecution. A coroner’s inquiry is pivotal in any decision process for laying charges. Without this due process, it left only the ‘gate keeper ‘and the likely compromised, HDC as the sole investigative authority to provide evidence in this case.
And the coroner is the only remaining independent authority that can assist a police investigation the HDC does not have some influencing control over
Question 8: Was the HDC investigation compromised, or even deliberately sabotaged, to ensure limiting breaches would be found?
The HDC sought input only one external independent expert advisor during its investigation. The question must be asked why was the same advisor used to report to the police? Was there an already pre-determined outcome? Was the likelihood of a balanced investigation compromised? In past HDC investigations involving a patient deaths, in this case multiple deaths, multiple advisor options have been sought.
Question 9 Part A: Did the HDC simply cover up culpability of the Nelson Marlborough DHB?
The surgeon registration is dependent on being under the supervision of two surgeons. It is a requirement of the employer to ensure these strict criteria is met for patient safety:
The HDC said, “I remain of the view that, in all the circumstances, it would have been prudent for Dr C to have discussed Mr A’s case with a peer before proceeding with the surgery, but accept my expert’s advice that it was reasonable for Dr C to have proceeded with an open cholecystectomy in this case. Accordingly, I do not find that Dr C breached the Code in respect of his decision to undertake surgery on Mr A”
The fact of the matter is that it was mandatory to seek peer review, at the very least, given the condition of employment, as well as the registration issue and the fact that the surgeon was under a pending review for the second time. Why and how would the HDC ever come to this outcome, in a pivotal case that ultimately protects all parties from any further external proceedings.
Question 11 Part B: Did the HDC fabricate facts to hide the issue that patients were entirely at risk from a less experienced, struggling surgeon? And did the Nelson Marlborough DHB allow procedures to be carried out without the required supervision and support mandated by the Medical Council of New Zealand?
Expert advice: “it would seem to have been reasonable for an open cholecystectomy to be performed by a senior surgeon with good support”
HDC “The Nelson Marlborough DHB knew that they had a surgeon who had skill deficiencies in laparoscopic cholecystectomy, and they addressed those issues in a way that seems appropriate and reasonable. Unless there had been concerns raised about judgement and other surgery, they would have no reason to expect that a senior well trained surgeon would have issues with what is a very common operation”
This statement becomes justifiably incorrect“unless there had been concerns raised about Dr C’s judgement and his performance of surgery other than laparoscopic cholecystectomies, NMDHB would have had no reason to expect that a senior, well trained surgeon would have issues with what is a very common operation. HDC went on to say “ Although I consider that the concerns with Dr C’s performance should have been seen as a warning signal, in all the circumstances, I do not consider that NMDHB breached the Code by allowing Dr C to continue performing surgery other than laparoscopic cholecystectomies” “
This is the key ‘out’ clause for the HDC being held liable on this question. They allowed the surgeon to operate on this patient in the unsupervised manner that he did. Remembering that the outcome from the first death was that the surgeon was said to be an experienced senior surgeon, as advised to the police by the external advisor.
Contradiction to this ‘out’ clause given by the HDC :
1. Did the surgeon lie on his CV about being experienced? If he did, criminal charges would most certainly follow. Easily confirmed by making enquiries by the HDC or the Police to the previous hospital employer:
Expert advised on Second surgery: Usually placing a tape around the portal structures is straightforward and can be safely done by feeling the important structures and the softer filmy tissue medial to these structures, then passing an instrument atraumatically behind to grasp a silastic vessel loop. I accept that [Dr C] is not a hepatobililary surgeon, but I can not ignore the fact that in his CV he claims to have been a course director for [a relevant] teaching programme and was involved in trauma surgery at his previous role as Head of the Divisions of General, Vascular and Thoracic surgery at [an overseas hospital]. A portal occlusive tape is a very useful and basic tool in trauma surgery. In light of this, passing the tape through the portal vein, the preterminal event, does seem hard to accept, and of course would be met with severe disapproval by other surgeons.
And to recap again:
Dr C stated that Dr D had never used the Rummel tourniquet technique previously either.
Dr C accepts that an injury to the portal vein occurred during the placement of the Rummel tourniquet, and that this was a surgical error on his part.
2. Did this statement also indicate the experience level of the surgeon in question not being an experienced surgeon? Highlighting the common fact that woman are twice as more likely to undergo a cholecystectomy for gallstones then men is not an out clause for negligence – failure of duty of care , nor is the fact that the patient has had previous surgeries.
- “ Overseas his surgery always involved assistants with varying degrees of surgical training, either consultant colleagues or registrars “ And confirm “it would have been prudent” should have really been “mandatory prerequisite”, given that the surgeon was under review yet again for patient injury and required to be under supervision as a condition of registration and as such subsequent employment conditions to be monitored by the DHB. And if so, did the HDC give a ‘free pass’.
- “Dr C stated to NMDHB that in New Zealand he had encountered a far greater number of unexpectedly difficult cases than he was used to. He attributed this to the greater degree of obesity in the younger, predominantly female, population compared to that which he had experienced overseas. Dr C said that in New Zealand patients there is a higher incidence of fibrosis and adhesions around the operative areas of cholecystectomies and that, prior to coming to New Zealand, his surgery always involved assistants with varying degrees of surgical training, either consultant colleagues or registrars. He noted that there were no registrars at the Hospital”
3. Was the requirements for supervision eluded to, given the fact the surgeon had just qualified as a “fellow of an overseas college of surgeons” one year before obtaining registration in New Zealand. All this occurred 2 and 3 years after cholecystectomies deaths, respectively.
More about becoming a Fellow: “Successful completion of the Basic Surgical Skills course prior to applying for the examination, 12 months surgical training in approved posts. (Training during community service cannot be submitted). Must include 6 months general surgery and 3 months ICU. 36 months in a numbered registrar training post”
More about the “The laparoscopic learning curve” resulting cause for high patient injury rates for inexperienced surgeons:
“The laparoscopic “learning curve” of the surgeon is a key-factor contributing to the high rates of bile duct injury. However, in comparison with air plane pilots, this surgical concept of learning curve is by some aspects ethically unacceptable.”
“In the Connecticut state audit reported by Orlando et al, 53% of the reported BDI occurred during the surgeon’s first ten cases, 33% between case 11-50 and only two cases (13%) after 50.”
A – Gigot, J.-Fr. Bile Duct Injury during Laparoscopic Cholecystectomy: Risk Factors, Mechanisms, Type, Severity and Immediate Detection. https://doi.org/10.1080/00015458.2003.11679400
4. How can the HDC claim this was a surgeon who was ‘experienced’ and ‘senior’ and that no breach occurred? Given the Nelson Marlborough DHB allowed the surgeon to operate when they were clearly making mistakes.
HDC: “The concern comes with the realisation that the subsequent bleeding was coming from the left hepatic artery. This means that although [Dr C] thought that the dissection was going adequately, in reality the dissection was going beyond the normal limits, and this was unrecognised. Using a blunt dissection technique requires knowledge of the local anatomy in the individual patient. If this cannot be safely confirmed, a subtotal cholecystectomy should be performed. This would be especially true with a self-knowledge of three recent injuries to the common bile duct.
And it goes on, summing up previous mistakes and failures:
“All injuries to the common bile duct occur because the surgeon does not realise the anatomy (which may be abnormal in this area quite commonly, and even more so after repeated inflammation), and so even more care should have been exercised. The decision to proceed with a full cholecystectomy in this situation, with this history and uncertain anatomy, would be viewed by most surgeons with moderate disapproval.”
Question 12: How and why does a procedure go from the risk difficulty of “more significant than a laparoscopic approach because of his age and the trauma to his body” to a “relatively uncomplicated” procedure?
As a result of this change the HDC find there is no breach and no need to consult with supervising colleagues about the risk of surgery, or justifying open surgery and it becomes ok for the surgeon to practice under their current restrictions.
Some Final feedback on police investigation:
Would a police or HDC investigation be confirmed as compromised if any of these questions where not investigated thoroughly? Concealment of information and/or breaches not revealed to the police would be tantamount to a civil conspiracy by the HDC, in collusion with the Nelson Marlborough DHB and the doctors in an agreement to defraud health consumers of their legal rights and to deceive the police.
Would any pre-existing protection assurance statements provide by the HDC to doctors and Health Service Providers, not supported by the HDC act, or Crimes Act, also meet a threshold of civil conspiracy? (i.e. Protective assurances to all parties affected; Government health providers, doctors and medical professionals, that they would never see the inside of a court room, even for criminal negligence)
If Informed consent was obtained illegally, by deceptive means or concealment of alternative treatment options, risks, side effects or any other information pertaining consumer rights; and
if the procedure should never have taken place in the first place; and
compiled with the fact the HDC failed to address these breaches,
would this also constitute a threshold for civil conspiracy? Arguably there is sufficient evidence to suggest that a direct specific intended outcome has been agreed upon to prevent the natural course of justice.
If the surgeon did lie about experience, in order to obtain employment , would this also not provide grounds for criminal proceedings. In a UK example, colleagues exposed the performance problems of a surgeon not matching their CV.
Example of Surgeon who lied about experience jailed for six years
A surgeon who lied about the number of operations he had carried out to get a lucrative job has been jailed for six years. Sudip Sarker, 48, told interviewers in 2011 he had performed 85 keyhole bowel operations, 51 of them working solo. The true figure was just six. He was appointed to an £84,000 job at the Alexandra Hospital in Redditch, but immediately struggled. Sarker, of Botany Road, Broadstairs, Kent, was convicted of fraud. Three of Sarker’s patients had subsequently died
8. Summary of a HDC Cover-up ?
As in the previous patient death investigation (11HDC00531) involving the same Nelson Marlborough DHB and the same surgeon, the HDC gave the surgeon a ‘free pass’ and a mandate to continue practicing in this manner. There was the withholding of information and failure to reveal alternative treatment options, the risk of side effects affecting quality of life and the risk of death.
As a direct result of the first patient tragedy, and many other ruling ‘free passes’, the HDC have effectively blocked the patient’s right to make an informed decision. The patients were put at risk, injures occurred and this patient died . The HDC signed off on a right to defraud its patients and give this surgeon the ‘OK’ to kill for the learning curve experience. This is a direct breach of the well-versed United Nations Universal Declaration of Human Rights, Article 3 that gives everyone the right “to life”.
Because of the protection offered by the HDC and the resulting deaths, the HDC have become an accessory to the fact and are involved in a conspiracy to prevent natural justice. There is a blatant breach of the Code of Health and Disability Services Consumers’ Right 6(2) and Right 7 and they are once again implicated in another cholecystectomy patient death.
Here is a summary of the ‘free passes’ given to the surgeon and the breaches of the Code identified in similar surgery investigations (but not in this investigation):
- The surgeon Demonstrated a lack of reasonable care and skill in deciding to perform surgery – breaching Right 4(1)
- There was a lack of support offered by (mandated supervising ) senior doctors and the Nelson Marlborough DHB, to provide services with reasonable care and skill – breaching Right 4(1) of the Code.
- There was sub-optimal documentation by clinical staff treating the patient and the DHB failed to ensure that its staff met expected standards of documentation – breaching Right 4(2).
- Failed to provide information, alternative treatment, risks involved, or possible side effects – that a reasonable consumer in his position would have needed to make an informed choice about treatment – breaching Right 6(2).
- As such, every consumer has the right to make an informed choice and give informed consent – Right 7(1)
- Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of that consumer. Right 4 (4). AKA the ‘right to life’ as found in the Universal Declaration of Human Rights Article 3.
And as follows here is a summary of the HDC actions/non-action in this case:
- HDC signed off it is ok for an open cholecystectomy procedure to be conducted without discussing with his supervisors – as was required by the terms of his medical registration for employment.
- HDC signed off it is ok to conduct surgery even under a restriction of practice for second time with two serious injuries and one death in a 24 month period and the fact the surgeon was facing a review by the Medical Council
- HDC signed off that it is ok when no documentation exists justifying the fact that the pain was actually gallstone related.
- HDC signed it off as ok when no alternative no surgical treatment options were presented when obtaining the consent of the patient.
- HDC signed off that it is ok (as per previous HDC rulings) for surgeons not to disclose the risks of side effects affecting their quality of life to patients, when obtaining their consent.
- HDC signed off that it is ok when a surgeon’s experience and training are overrepresented on their CV.
As a direct result of the lack of breaches found, especially breaches of common law and the fact that consent was not legally obtained (which is a criminal offence), the police investigation was terminated.
9. News reports References
More about: Informed Consent
Informed consent is legally required before a doctor can even touch a patient This is the very reason why the HDC was established, to protect the health consumers, not the health providers.
Key note: The HDC breached the patients’ rights by covering up the easily provable facts about Laparoscopic Cholecystectomy, Health consumers were not being advised of:
- Alternative treatment options
- Side effects risks affecting long term quality of life
- The direct risks of the surgery.
1] From an HDC perspective
‘My work as Commissioner over the past three years has been characterised by an emphasis on patients’ rights and responsibilities. A patient has a responsibility to share information that he or she knows to be relevant to the particular clinical decision. But I do not consider that a patient’s right to adequate information should be qualified by any duty or responsibility in using the information imparted. Many patients will prefer to leave decision making to their doctor
And goes on to conclude;
and Right 6(3)(b) of the Code recognises that patients are entitled to ask their doctor for a recommendation. Patients have a responsibility to make a decision, but how they do so is ultimately their business.
Keynote: This is the directive given to all doctors, their right to practice with clinical freedom is protected.
2] From a New Zealand Medical Association perspective
Key points made in ruling referenced by HDC “Director of Proceedings vs. Frizelle. Medical Practitioners Disciplinary Tribunal: Decision No. 219/02/94D; 3 December 2002. URL” 
- The current Code of Ethics of the New Zealand Medical Association records: “Doctors should ensure that patients are involved within the limits of their capacities, in understanding the nature of their problems, the range of possible solutions, as well as the likely benefits, risks, and costs, and shall assist them in making informed choices”.
- The approach taken by the High Court of Australia was strikingly similar to the standards, which the New Zealand Medical Council had enunciated.
“….that a doctor has a duty to warn a patient of a material risk inherent in the proposed treatment: a risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, warned of the risk, would be likely to attach significance to it.”
- The High Court of New Zealand B v The Medical Council of New Zealand
“In my view, the provision of inadequate information in a situation where the patient needs that information for his or her decisions affecting treatment or investigation, will almost always be professional misconduct or conduct unbecoming”.
3] From a legal perspective – What the law says
No one has the right to even touch, let alone treat another person. Any such act, done without permission (as a result of making informed consent), is classified as “battery” – physical assault and is punishable. The issue: Non-disclosure for the risks associated post removal of gallbladder and function and the false information provided about putting the patient’s safety at risk.
” The legal position regarding the provision of information needed to make an informed consent derives from the 1985 case of Sidaway v Board of Governors Bethlem Royal Hospital (Sidaway v Board of Governors Bethlem Royal and the Maudsley Hospital  2 WLR 480), where the House of Lords held that the legal standard to be used in deciding whether adequate information had been given to a patient would be the same as that in judging whether a doctor had been negligent in their care”
Roger vs. Whitaker. In this case the patient was already blind in one eye when the decision to operate on the other eye was made. The patient was not informed about the 1:14,000 chance of blindness as a possible result of the operation. The doctor was found to have breached his duty of care for not disclosing a risk of 1:14,000 because the patient’s circumstances (already blind in the other eye)
What constitutes a material risk surrounding the informed consent doctrine? Generally, the patient should be informed of all serious risks, even if unusual or rare. In one court case, a 1% risk of hearing loss required disclosure (Scott v. Wilson, 396 S.W.2d 532 [Tex. Civ. App. 1965]) In Canterbury, a young man was advised by his physician to undergo a laminectomy in an effort to alleviate back pain. The physician, aware that 1 per cent of laminectomies resulted in paralysis, did not advise the patient of the risk because he believed this might cause the patient to reject the useful treatment. Following the procedure, the patient fell from his hospital bed and was paralyzed. It remained uncertain whether the laminectomy procedure or the patient’s fall caused the paralysis. The patient sued, alleging that the physician failed to inform him of the risks associated with the procedure. The court held that “the standard measuring [physician] performance…is conduct which is reasonable under the circumstances”. In other words,the court held that, instead of adhering to the community disclosure standard, physicians are now required to disclose information if it is reasonable to do so. Essentially, to establish true informed consent, a physician is now required to disclose all risks that might affect a patient’s treatment decisions. In Canterbury, the decision outlined key pieces of information that a physician must disclose:
- condition being treated;
- nature and character of the proposed treatment or surgical procedure;
- anticipated results;
- recognized possible alternative forms of treatment; and
- recognized serious possible risks, complications, and anticipated benefits involved in the treatment or surgical procedure, as well as the recognized possible alternative forms of treatment, including non-treatment.
4] From a doctor’s ethical perspective
The ethical principle of autonomy which protects patient self-determination goes hand in hand with truth telling. Lying to and deceiving patients breach the autonomy of individuals and interferes with the doctrine of informed consent… Withholding information from patients impairs their decision-making capacity. Even when treatment options are limited, and prognosis is grave, knowing what to expect allows patients to prepare for what lies ahead instead of being overtaken by events.
Edwin, A. (2008). Don’t Lie but Don’t Tell the Whole Truth: The Therapeutic Privilege – Is it Ever Justified? Ghana Medical Journal, 42(4), 156–161. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673833/
The Nuremberg Code that guide Doctors ethics regarding medical interventions,
- Thevoluntary consent of the human subject is absolutely essential
- Exercise freepower of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion…
- Should have sufficient knowledge and comprehension of the elementsof the subject matter involved as to enable him/her to make an understanding and enlightened decision.
Carlson, Robert V, Kenneth M Boyd, and David J Webb. “The Revision of the Declaration of Helsinki: Past, Present and Future.” British Journal of Clinical Pharmacology 57.6 (2004): 695–713. PMC. Web. 4 Apr. 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884510/
Note: Ethical principles around consent:
The four main principles of medical ethics are 1] justice, 2] non-malificence, 3] autonomy and 4] beneficence. Autonomy is the main ethical consideration underlying informed consent. The patients’ right to determine what investigations and treatment to undergo must be respected by all doctors. For consent to be informed patients rely on the information provided by their doctor. Honesty and truthfulness are required to make the process of consent valid. The ethical principle of justice needs to be applied when deciding what treatments are offered to or withheld from patients. This touches the process of informed consent and is further explored when the right to demand certain treatments is discussed.
Note: Patient Autonomy (cornerstone of medical law, legal and ethical practice): The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.
Definition of Patient autonomy – MedicineNet: https://www.medicinenet.com/script/main/art.asp?articlekey=13551
5] From a Patients perspective
Department of Surgery, Christchurch Hospital Study: A questionnaire was developed from the Disability Commissioner’s Regulations (1996) and was administered to patients and doctors at Christchurch Hospital.
Results: According to patients the five most important aspects of informed consent were: (1) the major risks, (2) quality of life, (3) outcome, (4) consequences of not undergoing the procedure and (5) quantity of life.
Conclusion: “Both patients and doctors consider the explanations of risks and complications important, especially if the complication is serious and risk is greater than 1 in 1000. (0.01%) Patients consider aspects of outcome, quantity and quality of life important”
Newton-Howes PA1, Bedford ND, Dobbs BR, Frizelle FA. Informed consent: what do patients want to know Department of Surgery, Christchurch Hospital. https://www.ncbi.nlm.nih.gov/pubmed/9785548
Why Laparoscopic Cholecystectomy Surgeons lie?
Why would a reasonable surgeon lie to patients about alternative gallstone treatment options, expected risks and side effect risks affecting quality of life (Right 6 of the Code), in order to obtain consent for Cholecystectomies and/or even consider performing unneeded surgical procedures? From a surgeon’s perspective there are two distinct answers:
- We perform surgery because we have been trained to do so and because “we have always done it this way” or we simply do not know any better. In German psychology, this behavior is analogous to a historic entity termed “Funktionslust”
- We are incentivized to perform surgical procedures, either for financial gain, renown, or both
Philip F. StahelEmail author, Todd F. VanderHeiden and Fernando J. Kim. Why do surgeons continue to perform unnecessary surgery? https://doi.org/10.1186/s13037-016-0117-6
And why would a reasonable surgeon give provided inaccurate and incomplete testimony to the HDC or ACC treatment injury clinical reviews? Once explication can be found in the Medical Council of New Zealand Good Medical Practice guide for setting the standards for cultural competence, clinical competence and ethical conduct for doctors. It states
“You must cooperate fully with any formal inquiry or inquest into the treatment of a patient (although you have the right NOT to give evidence that may lead to criminal proceedings being taken against you)” . In other words a Doctor does NOT have to be forth coming with any information that would incriminate and lead to criminal proceedings
10. History – Surgeons have always lied about Laparoscopic Cholecystectomy
During the late 1980s operative techniques were challenged by alternative treatment including:
- Oral medical dissolution
- Percutaneous holecystostomy with stone extraction
- Percutaneous or transnasal topical solvent dissolution
- Extracorporeal shock wave lithotripsy,
This resulted in a marked decrease in surgeries performed; surgeons invented a new cash cow (bread and butter) income stream to recover from providential loss to alternative treatment options – the Laparoscopic cholecystectomy.
During the early 1990s adoption, there was seen a 29% increase in the number of cholecystectomies performed; with over a 100% increase in cholecystectomy for acute acalculous cholecystitis and 300% increase for biliary dyskinesia.
Problem for this new surgery procedure was twofold, patients were need for procedure development and training (experimentation), and justifications were needed for increased diagnoses for gallbladder removals to lower the threshold for diagnosing surgery treatment options. A story was invented and still in practice today as seen on all consent forms:
1] The gallbladder was, in fact, an unnecessary vestigial organ (prehistoric) not needed.
2] Once removed, the patient could return to a normal healthy diet and live a normal life.
3] With no likely side effect risks or digestive problems, as bile is now delivered directly to the stomach.
4] True injury rates risks trivialised or never disclosed
I.e. BDI risk rates are stated as 1:300 to 1:500 / 03%. But there are many evidence based medical studies stating risks are as high as 1.4%. (7x times higher than disclose rate of risk is a potential law suit of its own if it wasn’t for the HDC much published protection in place)
Note: There is no evidence-based medical study known to mankind backing these patient safety claims presented to patients in order to obtain consent. These are nothing more than dishonest, delusional revenue based fantasies.
Despite the formal recognition and endorsement of ethical principles set forth in the Nuremberg Code and Declaration of Helsinki by Doctors, the institutionalized development of laparoscopic cholecystectomy through leaning on ‘test subjects’ breach ethical, moral and legal standards. This infringement breaching all basic human right was deemed acceptable outcomes in a surgeon’s quest for the entrepreneurial exploration of the procedure, so too were the resulting deaths and serious injuries that followed.
Early in the nationalised experience with laparoscopic cholecystectomy it became apparent that some surgeons who were in the early phases of their training would misidentify the anatomy and inadvertently clip and divide the common bile duct thinking it to be the cystic duct. In many instances this would result in complete obstruction of the common bile duct, which would require a second operation to correct.
Bile Duct Injury reached epic levels as high of 15% (USA figures). These risks were never disclosed to new patients during the informed consent process. Surgeons training requirements were priority and patient injury was an acceptable outcome. Surgeons called this ‘development with patient partnership’ This did not reflect well for some doctors as the ethical principle of autonomy which protects patient self-determination goes hand in hand with truth telling. Many spoke out both publicly and in medical journals of their concerns
One study “Impaired Quality of Life 5 Years After Bile Duct Injury During Laparoscopic Cholecystectomy: A Prospective Analysis” exposed the long term risk to health with BDI as being, conclusion: Despite the excellent functional outcome after repair, the occurrence of a BDI has a great impact on the patient’s physical and mental QOL, even at long-term follow-up. One discussion feedback exposes cold ethical truth. Prof. A. Johnson: I too found these data fascinating. I think the two key questions are: What were the patients told before they had the operation in the first place? Were they warned about bile duct damage? And goes on to ask What should we tell patients if they should have the misfortune to have their bile ducts damaged?
Other problems have also been identified to occur following laparoscopic cholecystectomy. This includes entering the gall bladder and spilling stones and bile into the peritoneal cavity, failure to diagnose stones in the common bile duct, cystic duct clips falling off leading to bile peritonitis, holes being poked in the cystic dust while doing x-rays of the biliary tree (cholangiography), holes poked into the intestine or mesentery by either the needle used to fill the peritoneum with CO2 (Verness needle) or one of the trocars used to introduce the ports.
Laparoscopic Gallbladder Surgery Attorneys. www.laparoscopicsurgeryinfo.com/nih-press-release
11. More about the HDC protected fraud (New Zealand’s largest)
As noted earlier, the HDC breached the patients’ rights by covering up the easily provable facts about Laparoscopic Cholecystectomy, Health consumers were not being advised of:
- Alternative treatment options
- Side effects risks affecting long term quality of life
- The direct risks of the surgery.
In doing so, it is reconfirmed again; every health consumer’s consent for cholecystectomies in New Zealand is obtained illegally through deception and concealment, breaching the legally enforceable Code of Health and Disability Services Consumers’ Rights’ (Code of Rights)
More about: Alternative treatment options
Over the past several decades’ nonsurgical treatment of gallbladder stones were evaluated and gained some popularity, these included the following:
Note: District Health Boards advise the following, ‘It is very common that patients wait longer than 6 months if further diagnostic action, treatment or assessment by other specialties is required.’ Surgeons who doing nothing and offering no alternative non-surgical treatment options during this period could be considered as guaranteeing a further client for surgery and is a failure to provide a duty of care to the patient. This is a breach of Right 4(4), ‘Every consumer has the right to have services provided in a manner that minimises the potential harm to, and optimises the quality of life of the consumer.’ Alternative treatment options could have included diet changes and bile salt dissolution.
Queensland Government health Services: Cholecystectomy -Laparoscopic informed consent document
“Alternative treatments: Oral Dissolution Therapy. Oral dissolution therapy is the taking of chemicals by mouth to dissolve the gallstones. It is most effective for patients, who are not overweight, in a younger age group, have small or single gallstones and a gall bladder that is working well.
Cholecystectomy Laparoscopic consent form: https://www.health.qld.gov.au/__data/assets/pdf_file/0014/152204/hepatobiliary_01.pdf
More about non-surgical Treatment option – Dissolution of Gallstones: ursodeoxycholic acid, Actigal®, is a medicine that can be given as a pill to dissolve gallstones. Therapy requires at least 6 to 12 months and is successful in dissolving stones in 40-80% of cases. When surgery is too risky, the symptoms are mild, the stones are small, and rich in cholesterol, dissolution of gallstones is a reasonable alternative.
American College of Gastroenterology – Gallstones in Women
More about non-surgical treatment options: Cholesterol gallstone disease is a common clinical condition influenced by genetic factors, increasing age, female gender, and metabolic factors. Although laparoscopic cholecystectomy is currently considered the gold standard in treating patients with symptomatic gallstones, new perspectives regarding medical therapy of cholelithiasis are currently under discussion, also taking into account the pathogenesis of gallstones, the natural history of the disease and the analysis of the overall costs of therapy. A careful selection of patients may lead to successful non-surgical therapy in symptomatic subjects with a functioning gallbladder harboring small radiolucent stones. The classical oral litholysis by ursodeoxycholic acid has been recently paralleled by new experimental observations, suggesting that cholesterol-lowering agents which inhibit cholesterol synthesis (statins) or intestinal cholesterol absorption (ezetimibe), or drugs acting on specific nuclear receptors involved in cholesterol and bile acid homeostasis, might be proposed as additional approaches for treating cholesterol gallstones. In this review we discuss old, recent and future perspectives on medical treatment of cholesterol cholelithiasis.
Therapy of gallstone disease: What it was, what it is, what it will be. Portincasa P1, Ciaula AD, Bonfrate L, Wang DQ. https://www.ncbi.nlm.nih.gov/pubmed/22577615?dopt=Abstract
More about Ursodeoxycholic acid, 250 to 300, 500 to 600, or 900 to 1000 mg/d, was given orally for 6 to 38 months to 53 patients with cholesterol gallstones and functioning gallbladders. Forty-two patients (79%) had greater than 50% reduction in gallstone volume, number, or both, without apparent dose dependence and 27 (50%) of these patients had complete gallstone dissolution. Results of laboratory studies including liver function tests were not affected adversely and biliary lithocholic acid concentration did not increase during therapy. Most biliary symptoms seemed to disappear within 3 months and no patient developed diarrhea.
Thus, ursodeoxycholic acid appears to be a safe and effective alternative to surgery in selected patients with gallstones.
Tint GS, Salen G, Colalillo A, Graber D, Verga D, Speck J, Shefer S. Ursodeoxycholic acid: a safe and effective agent for dissolving cholesterol gallstones. https://www.ncbi.nlm.nih.gov/pubmed/7051912
More about Percutaneous cholecystostomy: (PC), a technique that consists of percutaneous catheter placement in the gallbladder lumen under imaging guidance, has become an alternative to surgical cholecystostomy in recent years. Indications of PC include calculous or acalculous cholecystitis, cholangitis, biliary obstruction and opacification of biliary ducts. It also provides a potential route for stone dissolution therapy and stone extraction. Response rates to PC in the literature are between the range of 56-100% as the variation of different patient population. (first performed by American surgeon, Dr. John Stough Bobbs, in 1867)
Akhan O1, Akinci D, Ozmen MN. Percutaneous cholecystostomy. https://www.ncbi.nlm.nih.gov/pubmed/12204405
Contact dissolution of cholesterol gallstones with organic solvents is emerging as a rapid, safe, alternative treatment for symptomatic cholesterol gallbladder stones. Placement of a percutaneous transhepatic catheter into the gallbladder is a rapid and safe technique. The availability of safe, effective cholesterol solvents and solvent transfer devices means that cholesterol gallbladder stones can be eliminated rapidly and safely by CDOS, without the risk of general anesthesia or surgical dissection of the gallbladder bed. Patients with single gallstones are better candidates for CDOS than are patients with multiple gallstones because recurrence after dissolution is less common. Contact dissolution may well be judged the treatment of choice by the medical-surgical gallstone management team in some patients.
Hofmann AF1, Schteingart CD, vanSonnenberg E, Esch O, Zakko SF. Contact dissolution of cholesterol gallstones with organic solvents. https://www.ncbi.nlm.nih.gov/pubmed/2022421
More about Extracorporeal shock-wave lithotripsy: Extracorporeal shock-wave lithotripsy (ESWL) is an infrequently used method for treating gallstones, particularly those lodged in bile ducts. ESWL generators produce shock waves outside of the body that are then focused on the gallstone. The shock waves shatter the gallstone, and the resulting pieces of the gallstone either drain into the intestine on their own or are extracted endoscopically. Shock waves also can be used to break up gallstones via special catheters passed through an endoscope at the time of ERCP.
Jay W. Marks, MD. Gallstones. https://www.medicinenet.com/gallstones/article.htm
More about bile acid dissolution therapy: Medical therapy with oral bile acids is appropriate for patients who present with small cholesterol stones and for patients with larger cholesterol gallstones who cannot or will not have surgery. Oral bile acids may also be valuable in the treatment of gallstone recurrence before it has become symptomatic or to prevent recurrence after prior success Am J Surg. 1989 Sep;158(3):198-204.
Hofmann AF. Medical dissolution of gallstones by oral bile acid therapy. The American Journal of Surgery. https://doi.org/10.1016/0002-9610(89)90252-3
More about how can watchful waiting help treat gallstones: Though a gallstone episode can be extremely painful or frightening, almost a third to half of all people who experience an attack never have a recurrence. In some cases, the stone dissolves or becomes dislodged. Because the problem may solve itself without intervention, many doctors take a wait-and-see approach following the initial episode.
More about: Side effect risks affecting quality of life
Postcholecystectomy syndrome: Postcholecystectomy Syndrome (PCS) describes the presence of abdominal symptoms after surgical removal of the gallbladder (cholecystectomy). Symptoms of Postcholecystectomy Syndrome may include: Upset stomach, nausea, and vomiting, gas, bloating, and diarrhoea. Persistent pain in the upper right abdomen. Symptoms occur in about 5 to 40 per cent of patients who undergo cholecystectomy, and can be transient, persistent or lifelong. The chronic condition is diagnosed in approximately 10% of postcholecystectomy cases. 
“The incidence of postcholecystectomy syndrome has been reported to be as high as 40% in one study, and the onset of symptoms may range from 2 days to 25 years. There may also be gender-specific risk factors for developing symptoms after cholecystectomy. In one study, the incidence of recurrent symptoms among female patients was 43%, compared to 28% of male patients.”
“Cholecystectomy is associated with several physiological changes in the upper gastrointestinal tract which may account for the persistence of symptoms or the development of new symptoms after gallbladder removal. The cholecyst sphincter of Oddi reflex, cholecyst-antral reflex, and cholecyst-oesophagal reflexes are all disrupted and some local upper gastrointestinal hormonal changes also occur after cholecystectomy. Thus, there is an increased incidence of gastritis, alkaline duodene gastric reflux and gastro-oesophageal reflux after cholecystectomy, all of which may be the basis for postcholecystectomy symptoms.” 
“Cholecystectomy can have nutritional and metabolic consequences in the short-term (diarrhea, abdominal pain and bloating) and in the long-term (increased Body Mass Index with metabolic syndrome, gastritis, liposoluble vitamin deficiency). Pathogenic mechanisms behind these disturbances are reviewed and the need for an early post-operative nutritional intervention based on low-lipid, high-fibers diet, is highlighted.
A physical activity together with a tailored nutritional planning for each patient could help to reduce ostsurgical complications following cholecystectomy and minimize symptoms, and a long-lasting educational program to change erroneous eating habits and to promote a varied and balanced diet, such as balanced diet, such as Mediterranean diet and lifestyle should be provided by clinicians and nutritionists 
- S Nogueira, L., Freedman, N. D., Engels, E. A., Warren, J. L., Castro, F., & Koshiol, J. (2014). Gallstones, Cholecystectomy, and Risk of Digestive System Cancers. American Journal of Epidemiology, 179(6), 731–739. http://doi.org/10.1093/aje/kwt322
- Zhang Y, Liu H, Li L, Ai M, Gong Z, He Y, et al. (2017) Cholecystectomy can increase the risk of colorectal cancer: A meta-analysis of 10 cohort studies. PLoS ONE 12(8): e0181852. https://doi.org/10.1371/journal.pone.0181852
- Wikipedia, Postcholecystectomy syndrome. https://en.wikipedia.org/wiki/Postcholecystectomy_syndrome
- S.S.JaunooS MohandasL.M.Almond. Postcholecystectomy syndrome (PCS) https://www.sciencedirect.com/science/article/pii/S1743919109001538
- Steen W Jensen, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF Postcholecystectomy Syndrome https://emedicine.medscape.com/article/192761-overview#showall
- Altomare DF, Rotelli MT, Palasciano N. Diet after cholecystectomy. https://doi.org/10.2174/0929867324666170518100053
- Wikipedia, Postcholecystectomy syndrome. https://en.wikipedia.org/wiki/Postcholecystectomy_syndrome