Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
8. FENTANYL INCIDENT
The alleged incident
8.1 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
giving the drug fentanyl to a patient who claimed she was allergic to this drug.
8.2 The patient was a nurse who worked on the medical ward at the hospital at the
time of this incident. In 1981 her dentist extracted her teeth and administered
fentanyl. The patient experienced anaphylactic shock and was admitted to
hospital. She was advised to wear a medic alert bracelet advising of her
allergy to fentanyl.
8.3 The patient’s medical record documented her previous allergy to fentanyl.
The patient said that she specifically requested that she not be administered
fentanyl. It was noted on the anaesthesia form that the patient had been given
fentanyl as part of the anaesthesia.
8.4 The operation took place on 22 December 1999. She was first on the surgery
list for that day. A consent form for treatment (surgery) and anaesthesia was
signed by the patient on the day of the operation in the presence of a house
surgeon. There is no note on the consent form about the patient’s fentanyl
allergy. There is an unsigned pre-admission examination form dated 22
December 1999 which contains the house surgeon’s writing. There is a
separate anaesthesia consent form also signed by the house surgeon. It
appears that there was no pre-anaesthetic clinic for this patient.
8.5 There is also an undated and unsigned pre-anaesthetic record which records
the patient’s allergy to fentanyl. The handwriting on this form matches that of
Dr Lucas. A reasonable inference can, therefore, be drawn that Dr Lucas filled
in this form. The form, under the heading “OTHER”, states: “Description of
allergy that of simple overdose in patient without IV fluids.” Under the
heading “PLAN”, the form states: “Give fentanyl under controlled conditions
to rule out allergy or idiosyncrasy and allow woman to have [fentanyl].”
8.6 The patient said in her original letter to NZNO: “I arrived in theatre to be met
by a rude and arrogant anaesthetist who informed me he was going to
anaesthetise me with IV fentanyl.”
8.7 The patient felt that her rights as a patient were violated because Dr Lucas
ignored her request not to be anaesthetised with fentanyl. The patient stated:
“He just arrived at induction and said that he was going to anaesthetise
me with IV fentanyl. Dr Lucas knew about me and my allergy to
fentanyl because he had my case notes. Nevertheless, Dr Lucas spoke to
me as though I was not even there, as though I was ‘nothing, just a
woman, just a Maori’. Dr Lucas put his face in my face and intimidated
me.”
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