Gisborne Hospital Report - Health and Disability Commissioner

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Gisborne Hospital 1999 – 2000 Operating Theatre Protocols Opinion I think it would be fair if you acknowledged the fact that more than one anaesthetist asked me how I did my spinals implying that my technique was worth emulating on the basis of its results. Why had they not chosen to emulate the anaesthetist that you quote in [para 6.25]?” 6.28 The use of ice by Dr Lucas was described as “aggressive” and by himself as “a trifle frenetic”, but there appears to be no evidence that it was clinically inappropriate. I accept my expert advice that Dr Lucas did not breach professional anaesthetic standards in his use of ice. Nor do I find any evidence that Dr Lucas breached ethical standards by using ice in an improper manner. Accordingly, in my opinion, Dr Lucas did not breach Right 4(2) of the Code by his use of ice. 6.29 Right 6(1) of the Code states that “every consumer has the right to all information that a reasonable consumer, in that consumer’s circumstances, would expect to receive”. 6.30 Dr Lucas noted that from 1982 to 1997 he treated countless Canadians in the same way as he did the women of Gisborne. In my opinion female patients in New Zealand, on whom ice is to be rubbed for anaesthetic purposes prior to a surgical procedure, would expect a reasonably full explanation of how and why the ice is to be applied. Any surgical patient is likely to be apprehensive about surgery and may be ill at ease in the unfamiliar surroundings of an operating theatre. A procedure which involves intimate parts of the body may cause additional stress and embarrassment. 6.31 One patient wrote to me that she did not “think it necessary to keep testing with the ice right on up to and including [her] bosom area”. This patient was entitled to an explanation of how and why Dr Lucas proposed to apply the ice. Had such an explanation been given, her concerns could have been alleviated, or another method of testing the level of an anaesthetic block could have been offered to her. 6.32 I note that, although a number of Dr Lucas’ nurse and anaesthetic technician colleagues expressed concern about his use of ice, only one of the many female patients on whom he used the technique complained about it, notwithstanding the widespread publicity in Gisborne about the allegations and the availability of my investigation team for interviews. 6.33 In these circumstances, I find that Dr Lucas failed to give one patient the information that a reasonable patient in her circumstances would have expected to receive, and therefore breached Right 6(1) of the Code. 7. TILTING THE OPERATING TABLE The alleged incidents 7.1 It was alleged that Dr Lucas failed to treat patients with respect and failed to provide services in a manner that respected the dignity of individuals by tilting 97
Gisborne Hospital 1999 – 2000 Operating Theatre Protocols the operating table on a number of occasions so that patients had to cling tightly to the table to stop sliding off. 7.2 NZNO stated in the letter to the Minister of Health: “The anaesthetist [Dr Lucas] claimed thick leather straps were essential to secure patients to the operating table. The Theatre Manager refused to order these items and the anaesthetist responded by tipping the table so women, especially Caesarean section women having epidurals, had to cling tightly to the table to stop sliding off. All the surgeons approached the Theatre Manager individually to urge the purchase of straps until the anaesthetist departed. Since then there have been no requests for straps.” 7.3 Dr Lucas denied tilting the table to obtain straps. He says he tilted the table “either because a 15 degree table tilt is standard of obstetrical care for Caesarean section or because table tilt was a necessity for laproscopic cholecystectomies”. 7.4 The theatre had canvas straps available. According to nurses and anaesthetic technicians, Dr Lucas disliked these straps and wanted new ones that would click on the side of the table. Dr Lucas said the available straps seemed difficult to use, were not reliably available in every theatre and because they did not attach to the edge of the table potentially would allow a leg to fall off the table. An anaesthetic technician described the existing straps as adequate and had suggested to Dr Lucas that boards be made to support the patients’ legs, but Dr Lucas wanted straps. The same technician described Dr Lucas tipping the table “to the extreme”. The technician commented that Dr Lucas did not have to tip the table to such a degree that the patient is “hanging on for dear life” but that a tilt was necessary for Caesarean section patients predelivery. Dr Lucas said that the necessary tilt for Caesarean is 15 degrees and that “may be seen as ‘extreme’ for the under-informed”. 7.5 The Charge Anaesthetic Technician discussed the restraints issue with Dr Lucas. She suggested that alternative leg supports be used instead of the theatre purchasing new straps. Dr Lucas was happy with this for a while but then returned to wanting straps. 7.6 The Theatre Manager claimed that only one doctor was in support of Dr Lucas’ request for straps, but the investigation team found that there was wide support for the use of straps. The Theatre Manager stated: “Staff are not used to strapping patients to flat tables. Mr Burton was the only doctor supportive of the idea. Since Dr Lucas left, no-one except Mr Burton has ever asked for table straps.” 7.7 A Gisborne Hospital surgeon reported that straps are used practically everywhere else except for Gisborne Hospital. He stated that they are important where the position of the patient is changed. In the surgeon’s opinion, Dr Lucas kept asking for the safety belts because he was serious about patient care. Dr Lucas went to Orthotics to show them how to make the belt. The surgeon stated that Dr Lucas “cared about the hospital where he was 98
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GISBORNE HOSPITAL 1999 - 2000 A rep
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Table of Contents Page Executive Su
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1. BACKGROUND EXECUTIVE SUMMARY 1.1
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3. THE ENVIRONMENT 3.1 My investiga
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pathologist, staff shortages and pr
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Gisborne Hospital 1999 - 2000 Intro
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Chapter 2 Quality Assurance Systems
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Gisborne Hospital 1999 - 2000 Quali
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Gisborne Hospital 1999 - 2000 Patie
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RECOMMENDATIONS Quality Assurance S
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Gisborne Hospital 1999 - 2000 Recom
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Gisborne Hospital 1999 - 2000 Recom
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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