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Over the course of years, patients at North Shore Hospital's gynaecological and obstetric theatres were examined and treated by medical students, without giving their consent.
In the obstetrics and gynaecological theatres at North Shore Hospital, patients were treated or examined by trainee doctors without giving their consent.
And the nurse who raised concerns was stood down for doing so.
Now a report that looked at the issues has made adverse comments about what happened, but has stopped short of saying the events had breached health's code of ethics on patient rights.
The former North Shore Hospital nurse, known as Registered Nurse A, contacted Stuff Circuit investigative journalist Paula Penfold to share her story. For years, she had been concerned with the processes around informed consent in the theatres where she worked.
"She says, 'you know, somebody that you hadn't consented to having their hands in your vagina, trying to find your cervix, would you want to know?' She says 'I would want to know, and I would want my children and my granddaughters to know," says Penfold.
Eventually, after her complaints were ignored, she went to the Health and Disability Commissioner Morag McDowell, who investigated and released the findings of her report in October.
That report found 'weaknesses in the systems' around obtaining informed consent at what was then Waitematā District Health Board.
But Registered Nurse A had much more to say.
"She wanted to describe what the process had been like, because it was a fight for her and even though there are aspects of the eventual finding that she's happy about, there are some that she's not, so she wanted the story to be told in a fuller way than the report ever could."
That story began in 2012, when Nurse A was concerned about medical staff not following protocols around getting informed consent from patients. She complained to the DHB, and it came back with updated policies.
But after a medical leave, she came back to the hospital in 2018 to find that things had 'significantly deteriorated in terms of issue of consent'," says Penfold.
Those issues of consent included "a dossier of more than 40 cases of varying types of concerns."
The report refers to two of these.
"One of them was a situation in which a woman had been examined vaginally by a junior doctor... she was already under anaesthetic and then the house officer, who's a doctor in training, was told by the junior doctor to do the same examination... for the purposes of teaching. As the nurse describes it, so that this house officer could find out where the cervix was."
In this case, Nurse A protested that the patient had not given consent for that, and that secondary examination didn't go ahead.
"Another situation was where Nurse A walked into the theatre to be met by a surgeon saying 'oh you're here, we better do it properly,' and so then updated the consent on the documentation.
"Nurse A says that if she had been allowed as a part of the investigation to go back into the DHB and find those records, she would have been able to show that there were two different coloured inks used, i.e. that the consent had been recorded after the woman was already anaesthetised."
For Nurse A, the concept of informed consent was straightforward.
"She talks about wanting to know - having the right to know - who's touching your body, who's going to be present and who's going to be carrying out the procedure. It's quite simple to her," says Penfold.
But it doesn't seem it was simple to her employer.
"One of the criticisms that the Commissioner makes of North Shore Hospital is that in large part its defences were around the fact that it's a teaching hospital and that as such it was almost implicit - I'm paraphrasing - but because it's a teaching hospital of course teaching is going to happen on women, on patients and if you were to seek explicit consent for every possibly situation then one of its arguments... was that the patient might say no and then that would interfere with training.
"The commissioner was very clear on that: that's not good enough. The purpose of consent is exactly that.
"The fact that they might say no is not a good enough reason to not ask them."
Monique Jonas, who teaches ethics to medical students at Auckland University, agrees.
"Informed consent is not just about patients agreeing to something, it's really about patients being able to make their own choice, and that means sometimes patients will refuse things and that's all part of informed consent."
In New Zealand, the Code of Health and Disability Services Consumers' Rights spells out what rights patients have, including the "Right to Make an Informed Choice and Give Informed Consent."
"[It's] really the anchor for informed consent and for how treatment decisions should be made in New Zealand," says Jonas.
At North Shore Hospital, Nurse A's colleagues grew increasingly hostile toward her, and in 2020 she was put on leave, before retiring nine years early.
Find the full story on today's episode of The Detail, and read Penfold's articles here and here.
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