Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
8.8 The patient reported being very frightened when she went under the
anaesthetic. She worried about her two small children and that she might not
be there for them at Christmas.
8.9 Theatre staff told Dr Lucas that the patient was allergic to fentanyl but he
ignored them. The patient thought that because her surgeon, Dr Burton, was
there she would be safe.
8.10 After the operation Dr Lucas told the patient that she was not allergic to
fentanyl, and that her dentist had overdosed her in 1981. The patient accepts
that she was overdosed because 100mg of fentanyl IV is probably an overdose.
However, at the time of the operation she said she “begged [Dr Lucas] not to
give me fentanyl as I was allergic to it”.
Staff observations
8.11 An incident form was completed:
“Patient brought to theatre with documentation stating allergy to
fentanyl with previous adverse affects from this drug. Noted on this
anaesthetic form that patient had been given this drug as part of
anaesthesia once patient had arrived in recovery. Discussed with
anaesthetist rationale for giving fentanyl. Patient monitored closely
during recovery phase. Nil adverse effects noted.” (Incident report no.
416, dated 22 December 1999.)
8.12 The incident form was completed by a nurse who said Dr Lucas filled up the
syringe and told the patient it was pethidine. To the recovery nurse he said,
“see, she was given fentanyl and nothing happened”. Dr Lucas said that he
“told no one that I had given [the patient] fentanyl until the end of the case.
Then, I told the recovery room staff and the patient.” Dr Lucas denies that he
told the patient that he was going to give her pethidine.
8.13 The investigation team asked the nurse to confirm that Dr Lucas had said he
was giving the patient pethidine, but in fact he gave the patient fentanyl. The
nurse replied “yes, on the nursing sheet it was recorded that she had a fentanyl
allergy. It was not recorded on Dr Lucas’ purple sheet.”
8.14 The nurse was asked by the investigation team about the comment on the
incident review form that there was careful discussion with the patient prior to
surgery. The nurse recalled that “there was a discussion of two to three
minutes” and said “I don’t believe there was a careful discussion”.
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