Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
He tried to persuade me not to have a ‘general’ for so long that I became
tearful. The ice treatment I had never struck before and found it difficult
to tell where the numbness stopped, and I also did not think it necessary
to keep testing with the ice right on up to and including my bosom area.
All in all, I was upset by the whole proceedings with Mr Lucas.
I did not like his manner, and feel it should be reported.”
Reports to management
6.13 There are varying accounts of how concerns about Dr Lucas’ use of ice was
brought to the Theatre Manager’s attention. A technician who had observed Dr
Lucas using ice thought one of her colleagues had advised the Theatre
Manager. According to the Theatre Manager this ice incident occurred on the
same day that she completed the incident form about Dr Lucas’ re-use of
syringes, which was in November 1999. The Theatre Manager’s undated
handwritten document, written after her return from leave on 11 October 1999,
referred to an anaesthetic technician reporting an ice incident. The Theatre
Manager has not been able to find this incident form.
6.14 The Charge Anaesthetic Technician was absent from the theatre when the ice
incident occurred on about Wednesday 10 November 1999. She was told
about it on her return. She was not sure what to do about her staff’s concerns
(two anaesthetic staff and several nurses were present at the meeting), so she
took the evening to think about it. When she got to work the next day she
happened to hear Dr Lucas ask for the name and phone number of the “ice
incident” patient. She was very concerned about this.
6.15 Dr Lucas responded to this as follows:
“Reading [para 6.14 of the Report] has given me new insight into a
situation that I had reported to Mr Madden and have reported to your
[investigation team]. It had to do with a patient who had been admitted
solely for an epidural steroid injection for chronic back pain, which I
did. When injecting the steroid, it is standard practice to verify the
position of the needle by injecting some local anaesthetic with it and
demonstrating an area of anaesthesia on the skin, in my case using ice. I
wanted to make a follow-up telephone call to the patient to ask about
possible side effects of the procedure and its effect on her pain. The
theatre nurses who would not use their access to the computer to obtain
the telephone number thwarted me in my efforts. I had no idea that the
ice-use dynamic was going on subversively in the background. Having
consultants contact their patients post operatively is seen by many as an
exemplary level of practice. I took this issue to Mr Madden but he was
unwilling or unable to persuade the nurses to give me a telephone
number.”
6.16 The Quality Co-ordinator informed the investigation team that she had never
received an incident form on any ice incident. A theatre nurse who had
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