A woman who suffered anaphylaxis and was put into an induced coma after routine surgery in a Melbourne hospital alleges staff gave her medicines they knew would lead to an allergic reaction.

More than two and a half years after the then 23-year-old woman attended the Royal Women’s hospital, she says she is still suffering from health problems and struggling to receive answers from medical authorities.

She has said pre-operative consent forms listing her medical allergies were dismissed and ignored by doctors. She also alleged that one of her medical forms was changed to state that she had consented to the use of drugs she had listed on multiple forms as ones she had reactions to.

The woman, who declined to be named, is a singer and was preparing to tour. She wanted to ensure she was in good health before travelling overseas, and scheduled an appointment with a specialist at the hospital to receive advice about a small cyst on her ovary.

“The gynaecologist I saw told me he wanted to do surgery to look into what was going on, and that he would replace my IUD at the same time.”

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On multiple medical forms seen by Guardian Australia, the woman listed allergies to latex, which she said gave her burn-like welts; penicillin, which she said led to anaphylaxis; and opioids, which she said triggered a pancreatic attack including spasms of the muscular valve between the pancreas and the small intestine. These allergies were included in a pre-admission checklist, on her anaesthetic chart, on a pre-operative assessment chart and on the hospital medication chart. Her pre-operative chart noted she had been admitted to hospital with pancreatitis and muscle spasms in 2014.



But on the day of her surgery in early 2016, a note was added to her pre-operative report in different handwriting and a different coloured pen, which said “patient is happy to have fentanyl and hyoscine too”. Hyoscine is used to relieve muscle spasms; fentanyl is an opioid.



The woman said she had not consented to opioids at any stage. She said she was terrified of opioids because of her previous reactions to the drugs, and she had specifically mentioned fentanyl to the anaesthetist.

The woman said shortly before the operation the anaesthetist had told her fentanyl did not cause pancreatitis or muscular valve spasm. She said she still had not consented to its use. Guardian Australia has seen medical advice from the woman’s previous specialists stating she should not be given opioids.

The anaesthetist then said she might be given a “cousin drug” to fentanyl, named sufentanil, which had a smaller risk of reaction with her condition. The woman told the anaesthetist she had no experience or knowledge of the drug, which is a much more potent opioid than fentanyl, but that her specialists had told her to avoid all opiates.

Once she was unconscious, the anaesthetist gave her an antibiotic, cefazolin, which has a low risk of cross-reactivity with penicillin, but which is not recommended in patients with a reported penicillin allergy. The anaesthetist also administered fentanyl. The woman then went into anaphylaxis and had to be resuscitated on the operating table. She was placed into an induced coma and transferred to the intensive care unit of Royal Melbourne hospital.



When the woman complained to the Health Complaints Commissioner, she said she had been told by an investigator that it would be her word against the anaesthetist’s as to whether she had verbally consented before the operation.



“The fact is that a situation exists where it is the doctor’s word against a patient’s,” the woman said. “The quality of life I now live is not something I would wish on anyone. I have lost the ability to do things in life that gave me purpose and joy.” She said she suffered from severe abdominal pain that radiated to her back, and was too traumatised to see specialists.



The woman said the intubation required during resuscitation and intensive care had damaged her singing voice and affected her career.



In a meeting between the woman, her carer and a senior specialist at the hospital in May 2016, after her complaint, the specialist said it was strange that her anaesthetist had suggested sufentanil as an alternative to fentanyl on the day of her surgery, given that it was not used by the hospital. The woman, who took notes at the meeting, said the specialist had acknowledged she would not have known the name of the drug unless it was told to her specifically, given its rarity. He said that given her reactions to opioids, alternative pain management plans should have been proposed.



The woman said she felt the anaesthetist had treated her as though she did not know what she was talking about.

“This is gaslighting,” she said. “Both during the consultation and ever since. Trying to make me doubt myself or believe I am crazy or wrong. Trying to make me doubt my knowledge of my own body. Trying to make me doubt what I experienced, or my memory, or my knowledge.”

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Almost three years later, she is still in a battle with the hospital for answers, and has not had a resolution with the HCC. She has lodged a complaint with the Australian Health Practitioner Regulation Agency, which has confirmed it is investigating. The agency was unable to comment further due to confidentiality provisions.



The Victorian health minister, Jill Hennessy, told Guardian Australia that “patients who are left distressed by their experience at hospital shouldn’t have to wait years to get the closure they seek after their experience”. Hennessy said she had asked the HCC to give the woman’s conciliation process the highest priority.



The Health Complaints Commissioner, Karen Cusack, confirmed that a complaint about the woman’s treatment was first received in February 2016.



“The direct resolution process was unsuccessful and the complaint was subsequently referred to a HCC senior resolutions officer for conciliation,” Cusack said. “The complexity of a complaint will determine how long it takes to resolve. The conciliation process for this complaint remains ongoing.”

The woman said she had provided extensive documentation to investigators, including her medical consent forms, and that she could not understand how it had taken so long to get answers.



The chief executive of the Royal Women’s hospital, Dr Sue Matthews said: “We are sorry about the experience [the woman] had at our hospital.



“While we do not comment on the details of individual cases, the incident was investigated immediately in February 2016 and through our review processes. We have met with [the woman] to address her concerns and are continuing to work with the Health Complaints Commissioner through the conciliation process.”

Do you know more? melissa.davey@theguardian.com





