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• A cardiothoracic surgeon mistakenly removed the wrong lung lobe from a cancer patient, causing severe consequences.
• The Health and Disability Commissioner ordered the surgeon to apologise and undergo further training.
• The patient, Mr A, now has inoperable cancer due to the error and subsequent surgeries.

A surgeon mistakenly removed the wrong part of a cancer patient’s lung when operating to remove a tumour, resulting in the patient eventually losing the entire lung.

Now, the man has cancer in his other lung but it cannot be operated on due to it being his only lung.

In a complaint to the Health and Disability Commissioner (HDC) about the man’s treatment in 2020, his daughter said he has had a difficult and painful recovery over the past three and a half years and has been unable to return to work.

“Beyond this pain and lost income, my father has not been able to do the activities of life that bring him joy, such as physical activities,” she said.

“Now he has cancer in the lower right lobe of his lung. Because of having no left lung, his cancer is inoperable.

“The consequences of this accident are severe for my father and our family.”

Today’s HDC report on the matter detailed how the patient, referred to as Mr A, was diagnosed with lung cancer in the left lower lobe of his lung.

A cardiothoracic surgeon, referred to as Dr B, operated to remove the tumour, but subsequently, it was discovered that the left upper lobe had been mistakenly removed instead.

The man, in his 60s, required further surgery to remove the left lower lobe of his lung.

According to the report, Health and Disability Commissioner Morag McDowell identified several issues for investigation.

These included whether the surgeon provided the patient with an appropriate standard of care, whether he effectively communicated the outcome of the surgery performed and whether he provided appropriate information and obtained the patient’s informed consent for the surgery.

Dr Richard Bunton, head of the Department of Cardiothoracic Surgery at Dunedin Hospital, was asked to provide independent clinical advice on the case.

He told the HDC that the initial surgery, where the wrong section of the lung was removed, was a major error in judgment on the part of the surgeon.

Bunton said it ultimately caused the patient to lose the whole lung due to the need for further surgery.

“The reasons why Dr B became disorientated and removed the wrong lobe really can only be answered by Dr B himself.

“It certainly is difficult to understand from a purely objective point of view how this could occur but clearly it did.

“Dr B was clearly disorientated at the time of surgery.”

Thoracoscopic surgery was done within a confined space with various telescopes and optics.

“However, there is no resigning from the fact that the result was due to a major error in judgment and removal of the wrong lobe in such a patient would be considered to be a severe departure from accepted practice,” Bunton said.

“It is hard to imagine how this could occur in the hands of an experienced surgeon.

Dr B rejected the mistake occurred because of disorientation or an error of judgment.

He said he was fully aware the procedure was a lower lobectomy, and he proceeded to remove the lobe that was visible on the right side of the fissure - which was the left lower lobe.

However, Dr B said neither he nor anyone else involved in the surgery were aware that a torsion had occurred, and that the lung had rotated.

He assessed the orientation of the lung at every stage of the procedure through a video monitor, and it was unfortunate that he did not recognise the torsion that occurred after the lung was inflated and deflated, Dr B told the HDC.

“This gentleman underwent a lobectomy a week ago during which time he was meant to be having lower lobectomy for adenocarcinoma.

“Obviously I lost orientation due to torsion of the lower lobe during the VATS lobectomy and having had divided the inferior pulmonary ligament and vein.

“Mistakenly I performed right upper lobectomy thinking it was the lower lobe as the lung had twisted on itself 180 degrees.”

Dr B and Health New Zealand accepted the removal of the incorrect lobe of the lung should not have happened.

Health NZ told the HDC that Dr B had accepted “full and sole responsibility for the error in removing the incorrect lobe and that Dr B has unreservedly apologised to Mr A and his wife in person”.

Dr B performed the patient’s second surgery eight days later and found a twisted left lower lobe with its divided inferior vein and ligament infarcted (the tissue was dead).

The message was relayed to the patient’s wife, and it was explained that the left upper lobectomy was mistakenly undertaken a week prior.

Health and Disability Commissioner Morag McDowell investigated the complaint.

Mr A was discharged five days later and a plan was made for him to be reviewed in the coming weeks by his GP and at the cardiothoracic clinic.

However, the cancer later returned and was now in the right lower lobe of his only remaining lung.

Mr A raised concerns with the HDC about the information provided to him before the second surgery.

He said Dr B did not inform him of the error in the first surgery until after the second surgery had been completed.

He said Dr B had told him the second surgery was required because the blood supply to the remaining part of his left lung had been compromised.

He consented to further surgery after a brief discussion with Dr B during which he was informed that there was no other course of action available and that the left lung had to be removed.

Mr A said that because he was being told this by his surgeon, he took it as fact.

The clinical records show that Mr A was informed of the error two days before the second surgery.

There was nothing in the clinical records to indicate that Dr B had any further discussions with Mr A about the reasons for the second surgery, and there was no record as to what exactly was discussed with Mr A in relation to the error, prior to the second surgery being performed.

Dr B said he advised Mr A that he would let him know all the findings of the second operation when he finished.

“I did openly disclose the details of the error and its consequences to Mr A and his family as soon as I finished the second operation.

“It was only at this stage that I could confirm that the wrong lobe was removed.

“The remaining lung was found to be in a ‘rotated position inside the chest’, the position explains how the error had occurred (due to torsion).

“I advised this to Mr A at this stage and I apologised.”

Health NZ said Dr B accepted that for Mr A to have provided fully informed consent for his second operation, it should have been explained that removal of the incorrect lobe was in one possible explanation for the absence of cancer within the resected lobe and the compromised circulation evident on a CT scan.

Dr B apologised for that omission while it was pointed out that he had admitted the technical error to Mr A’s wife after the second operation and in person to Mr A after he had recovered from the anaesthetic.

“I acknowledge that I inadvertently removed Mr A’s left upper lobe instead of his lower lobe.

“This was an accidental and unrecognised error at the time of the first surgery, resulting in the need for a completion pneumonectomy.

“I very much wish this had not been the case and have no hesitation in taking this opportunity to apologise to Mr A again.

“I also acknowledge that Mr A has undergone a lot of difficulties because of this.

“Once again I acknowledge that an error was made on my part, as a very rare event and I once again apologise for the significant distress and added difficulties that this has caused Mr A.”

The HDC recommended Dr B provide the patient with a formal written apology for the deficiencies in the care he provided, undertake an audit of his other surgeries to ensure there were no other similar events, and undertake further training.