Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
completed a formal incident form commented: “I don’t know where the report
is. We didn’t get any feedback on the incident report. To my knowledge there
were no other channels available. I thought incident reporting was the proper
channel.”
6.17 The Group Manager (Hospital) commented in his interview on the lack of
reporting of the allegations regarding “unconscious women having ice rubbed
on their breasts. None of these matters were formally documented or
reported.”
6.18 The Chief Executive reported learning of staff concerns about Dr Lucas’ use
of ice through either the Clinical Director (Surgery) or the Group Manager
(Hospital). The Chief Executive was advised that she needed to know about
the allegations of inappropriate use of ice. “The concern was that there may
be inappropriate behaviour with sexual implications.” The Chief Executive
then received feedback that Dr Lucas was using ice but was using it
appropriately.
Dr Lucas’ explanation
6.19 Dr Lucas responded as follows:
“This procedure was carried out in standard fashion for proper medical
reasons. The skin level of anaesthesia necessary for a comfortable intraabdominal
procedure, regardless of its location, is the fourth thoracic
dermatome. The skin landmarks for this level are the nipples (on male
and female). The state of the art method of testing the level of
anaesthesia is with an ice cube. It provides a uniform stimulus unlike a
needle and unlike a needle, does not injure. The testing for the level of
block is done immediately, rapidly and repeatedly once the spinal
medicine is administered, as head up or head down positioning of the
patient can influence the level of the block, if done quickly. The whole
procedure is a trifle frenetic and the level is established in less than ten
minutes. The procedure is done with some sensitivity to modesty and
the gown is left across the chest and is pulled up no more than is
necessary for the testing. If, during that process, a nurse or a technician
continually pulls the gown down to obscure where I am testing, they will
be criticised for getting in my way. I think it is important to ask how my
anaesthetics for Caesarean sections compared in terms of quality, speed
and safety, with those of the other anaesthetists. I can say that more than
one of the local anaesthetists had asked me about the details of my
technique of doing a spinal.
I might add that between the years of 1982 and 1997 I worked in
Vancouver’s tertiary obstetrical hospital and treated countless Canadians
just the same as I did the women of Gisborne.”
Management response
6.20 The Theatre Manager reported to the Group Manager (Hospital) what she had
been told about Dr Lucas’ use of ice. The incident was treated as serious in
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