Full Breakdown
Anaesthetist Breaches Patient Rights After Administering Prohibited Sevoflurane
5/5/2026, 12:19:30 AM
Patient Request and Surgical Plan
In April 2020 a female doctor had hip-repair surgery at a private New Zealand hospital. Before the operation she emailed the surgeon’s secretary requesting sevoflurane be excluded because of a family history of malignant hyperthermia and that propofol be used instead. The anaesthetist, Dr B, initially expressed apprehension but confirmed propofol would be used and sevoflurane would not.
Intra-operative Sevoflurane Use
During the operation monitoring indicated a risk of the patient regaining consciousness. The IV line delivering propofol became obstructed, preventing anaesthetic delivery. Dr B gave a low dose of sevoflurane to maintain anaesthesia, then restored the IV line and completed the procedure without further sevoflurane. The automated record logged the dose but omitted the reason or the obstruction.
HDC Investigation Findings
The Health & Disability Commissioner (HDC) investigated after the patient complained. Commissioner Morag McDowell found Dr B breached the Health Consumers’ Code by not disclosing the sevoflurane use, describing the omission as a “severe departure from accepted standards”. The HDC noted missing documentation of the IV obstruction, contrary to Medical Council guidelines. Independent clinical advice deemed the temporary sevoflurane use appropriate, but the failure to inform the patient violated her rights.
Patient Outcomes
One week after surgery the patient was readmitted with acute kidney injury; months later she was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome. The HDC did not attribute these conditions to the sevoflurane use, leaving causality unresolved.
Official Statements
The HDC said documentation must record clinical context, options discussed, and decision rationale. Dr B said maintaining anaesthesia was his priority and sevoflurane was the only viable option while the IV line was blocked. He acknowledged he did not document the event in the clinical notes.
Criticism
Critics said withholding the drug information breached informed-consent principles and that missing documentation undermined accountability and safety.
Verbatim Quotes
- “did not consider it to be important” — Dr B, Anaesthetist
- “severe departure from accepted standards” — Morag McDowell, Health & Disability Commissioner
- “This action was necessary because of an IV-line obstruction that temporarily prevented her from receiving IV anaesthetic, resulting in a risk of her regaining consciousness during surgery,” — Morag McDowell, HDC
- “initially apprehensive” — Patient (doctor)
Timeline
- April 2020 – Hip-repair surgery; patient requested propofol, no sevoflurane.
- During surgery – IV line obstruction; low-dose sevoflurane administered.
- One week post-op – Acute kidney injury readmission.
- Months later – Diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome.
- December 2021 – Dr B retired; 2024 – HDC released findings.
What’s Next
The HDC report urges stricter adherence to informed-consent protocols and comprehensive anaesthetic documentation. Ongoing monitoring of the patient will determine if further clinical review is needed.
