Health NZ has been recommended to apologise to a man who received a full circumcision without his consent.
The man was first seen by a consultant urologist via a telehealth appointment – due to a thin, white, scaly inflammatory patch on the foreskin of the penis, known as balanitis xerotica obliterans, or XBO.
While explaining the surgical procedure to treat the condition, the consultant said there was a chance circumcision would be required once the surgery started, which could result in a partial or full circumcision.
The man told the urologist he would not consent to full circumcision. The Health and Disability Commissioner noted he was not provided with written information about the procedure, nor was he provided with a copy of the consultation documentation.
During the telehealth appointment, the doctor said: “When talking on the phone it is of course not possible to know exactly the state of the foreskin, so that would be discussed at the time of consent with [the] patient present.”
He did not obtain official consent at this time – and the doctor added it would have expired if he had, due to the estimated time between the consultation and the surgery.
On the day of surgery, the man met the operating surgeon, who was different to the consultant urologist. The surgeon said the usual treatment for XBO was a circumcision, so proceeded on that basis, noting this on the consent form having discussed the procedure with the man prior.
The man said he was confused by the terminology used but he later signed a consent form assuming the cutting or removal of the scar tissue on the frenulum was a form of partial circumcision. He did not knowingly consent to a full circumcision.
It is then noted the man again reiterated in the operating theatre he did not want a full circumcision. However, as no one raised the concern with the operating surgeon, a full circumcision was completed.
The medical director of surgical services for Health NZ said a partial circumcision of half of the foreskin would have left an “unsatisfactory flap” of remaining foreskin and been an “inappropriate operation”.
“A ‘partial circumcision’ was only an appropriate option if a small area of foreskin was involved, and it could have been managed with a small ‘excision biopsy’.”
The urologist also noted the man’s condition was a progressive disease, and a full circumcision was the standard of care.
Findings
Deputy health and disability commissioner Dr Vanessa Caldwell’s report found the man’s understanding of the procedure differed from what was listed on the consent form and departed from the expected standard of care.
There was a lack of clarity about the extent of the procedure, wasn’t given written information, and wasn’t told that a different person may carry out the operation at the initial consultation.
Caldwell also found the consenting took place in an inappropriate place, and there was a lack of mutual understanding among the providers.
It was noted this resulted from ineffective communication processes, which contributed to the man’s unexpected surgical outcome.
Following this, Health NZ has made changes including that the theatre operational leadership team will continue regular audits of consent forms of patients presenting for elective surgery.
Caldwell recommended Health NZ provide a formal written apology to the man; provide an update to HDC on its implementation of a new system that supports sharing of clinical appointment letters with its patients; and remind staff that patients should be given adequate time and opportunities to ask questions about the proposed surgery.
Who is responsible for consent?
Guidelines from the Medical Council of New Zealand stated the doctor undertaking the treatment was responsible for the overall informed consent process.
It stated: “Obtaining consent is a process of shared decision-making where you help the patient understand their medical condition and the options for treating (or not treating) that condition. It is more than signing forms and completing paperwork.
“Take the time to ask questions so that you understand what matters to your patient, and what their concerns, wishes, goals and values are.”
