Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
4. Post-Anaesthesia Information (if not recorded elsewhere)
4.1 Respiratory, cardio-vascular and neurological status and any other
relevant information.
4.2 Incidents arising during this period and their management.
4.3 Plan for pain management, fluid therapy and oxygen therapy for first
24 hours, especially for guidance of Recovery Room Staff.
4.4 Space for documenting/recording outcome data, including Clinical
Indicators, audit and quality assurance information.
4.5 Space for documenting the post-anaesthesia visit.”
Opinion
11.12 There is no evidence that Dr Lucas failed to comply with professional
standards in relation to his documentation and charting of medication. In my
opinion, the allegations made about Dr Lucas’ anaesthetic records were
unfounded. Accordingly, Dr Lucas did not breach Right 4(2) of the Code in
relation to this matter.
12. UNLABELLED SYRINGES
The alleged incidents
12.1 The NZNO letter to the Minister stated:
“Recovery nurses gave evidence that the anaesthetist would come to
recovery with unlabelled filled syringes in his pocket and instruct them
to administer the medication. They refused.”
12.2 NZNO submitted that nurses working in recovery reported:
“[Dr Lucas coming to the recovery room] with filled, unlabelled syringes
in his pocket and instructing them to administer the contents to patients.
As the nurses did not know what the contents were they refused. This
was reported to the internal hospital investigation of re-use of syringes.
At least three recovery room nurses told the [internal] inquiry that this
was Dr Lucas’ established and usual practice.”
12.3 The investigation team received only one piece of direct evidence of
unlabelled syringes being used by Dr Lucas. A nurse said in her interview
with Dr Bruce Duncan that Dr Lucas “would bring syringes from operating
room which were unlabelled “and that she would discard them”.
12.4 Another nurse stated: “Only on one occasion did I see Brian Lucas re-use a
syringe, and it was the time he produced the syringe from his sleeve. In that
case I think he injected it into a luer, as it was early on in a case.”
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