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• Ian Tollemache is seeking answers after a surgeon mistakenly removed the wrong part of his lung. 
• The Health and Disability Commissioner found the doctor to be in breach of three codes, including informed consent. 
• Health NZ conducted an internal review but found no broader systems issues; improvements are ongoing. 

A cancer patient says he’s still seeking answers around how a surgeon mistakenly removed the wrong part of his lung nearly five years on. 

Ian Tollemache was an unnamed patient mentioned in last month’s Health and Disability Commissioner (HDC) report involved in a botched surgery in 2020. 

Corrective surgery eight days later removed the cancerous tumour with his whole left lung but meant the cancer that had since developed in his remaining lung was inoperable. 

Despite the HDC investigation finding the doctor in breach of three codes, including not giving Tollemache informed consent before the corrective surgery, he remained dissatisfied with the report. 

“I wanted two things out of it, I want to know how it happened and what event caused this,” Tollemache said. 

“They still haven’t told me how the actual incident of cutting the wrong bit out and [leaving] the right bit behind with a blood supply ... I still don’t know how he did that.” 

Tollemache wanted to know what was being done to prevent this from happening again. 

Ian Tollemache was an unnamed patient mentioned in last month's Health and Disability Commissioner report involved in a botched surgery in 2020. 

The surgeon claimed the error was a result of the lung rotating without detection. 

That’s despite independent clinical advice from the University of Otago’s Dr Richard Bunton, who said this was the first reported case he had seen where the wrong lobe had been removed. 

“It is a little difficult to understand why ‘alarm bells’ did not ring when after dividing the inferior pulmonary vein [to the lower lobe], which [Dr B] clearly did, he went on to divide the upper lobe,” Bunton said in the report. 

“This vein is situated in the anterior-superior position of the hilum and clearly not related to the lower lobe.” 

The HDC report released in February said there was no indication of any broader systems or organisational issues at Health NZ and no codes of conduct were breached. 

But the former patient said he remained concerned about many aspects of his experience at the unnamed hospital. 

“The hospital wasn’t found guilty of breaching my rights, but I still think it breached both my rights, to be caught in the system and not fully informed. 

“They shouldn’t have allowed him to give me false information and they should have done some work to help him because he’d made a mistake that he’d never done in more than 300 operations.” 

Tollemache said he doesn’t want to vilify the doctor, expressing concerns around how he was supported after the medical mistake and what the hospital was doing to prevent an error like this being repeated. 

The HDC report said the doctor continued to perform video-assisted thoracoscopic surgery (VATS) lobectomies and now marked the lobe to be resected with ink, so that it was recognised in the event of torsion or rotation. 

“I don’t see how that’s going to solve the problem because he had a dye marker on my lobe anyway and he didn’t stop to check why he couldn’t see what he was meant to be seeing when he removed my upper lobe,” Tollemache said. 

Tollemache’s daughter Dr Cherie Tollemache remembered the moment the doctor told her father that a mistake had occurred. 

“I’ve never seen a person that distressed in my entire life, this doctor was shaking and couldn’t form words; he was crying and was so impacted by his mistake and the consequences,” she said. 

“We still have unanswered questions about the accident itself, the hospital response to the accident and the ACC systems for supporting the victims of medical accidents and accidents that cause permanent disability. 

“We hope to drive attention towards hospital process issues that are possible to fix if the motivation is there. 

“We hope to drive the public to shout about healthcare reform so that the politicians commit to prioritising the health of their constituents, the citizens of New Zealand whom they are meant to serve.” 

The family said they were led to believe there was no investigation into the botched surgery until they initiated it with the HDC. 

RNZ took the family’s concerns to Health NZ, who said in a statement that an internal review was carried out after the surgery, which was completed before the HDC investigation. 

But Health NZ said there was no further understanding as to how the accident happened and it wouldn’t comment on whether the surgeon had been given psychological support. 

“Health New Zealand acknowledges the Health and Disability Commissioner’s findings and would like to take the opportunity to recognise the experience of this patient in 2020,” said a Health NZ spokesperson. 

“While the commissioner found Health NZ did not breach the Code of Health and Disabilities Services Consumers' Rights, we want to reassure the public that we take our obligations and responsibilities very seriously. 

“Work is ongoing to develop a nationally consistent approach to informed consent and Health NZ is committed to improving processes and ensuring patients have a positive experience. 

“Providing safe, high-quality care to our patients is our top priority. 

“As always, we encourage patients and whānau to talk to us directly if they have questions about their care, or to contact the Health and Disability Commissioner for an independent review.” 

Health NZ said improvements have followed this event and are included in the HDC report. 

- Victor Waters, RNZ