Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
12.9 My expert anaesthetist stated:
“There seems to be no suggestion that Dr Lucas asked nurses to
administer drugs from unlabelled syringes except in his presence on
occasions when it was physically easier for them to do so. This is not
uncommon practice in the operating theatre and also occurs in the
recovery room. Whilst it might be conceded that in ideal circumstances
the nurse would wish to have seen the ampoule opened, read its label
and witnessed the contents being drawn up, this is rarely the case.
Simply having a syringe with a label on it would not provide the nurse
with any assurance as to the contents of the syringe. Syringe size and
other identifying features is used by some to indicate what type of
medicine is in a syringe.”
Opinion
12.10 I accept the advice of my expert anaesthetist that Dr Lucas did not act
inappropriately in asking nurses to administer drugs from unlabelled syringes
in his presence. In my opinion, Dr Lucas exercised reasonable care and skill
in his instructions to nurse colleagues about the administration of drugs.
Accordingly, Dr Lucas did not breach Right 4(1) in relation to this matter.
13. WAKING PATIENTS EARLY AND PUTTING CONSCIOUS
PATIENTS IN THE LITHOTOMY POSITION
The alleged incidents
13.1 It is alleged that on more than one occasion Dr Lucas woke patients early,
while they were still being sewn up and/or were still in the lithotomy
position.
13.2 Several anaesthetic technicians and theatre nurses recalled that sometimes Dr
Lucas’ patients would wake early.
13.3 An anaesthetic technician described a situation where a patient was allowed
to wake early:
“If [Dr Lucas] was angry he would go red in the face and yell. Then
everything was wrong. Everybody paid the price. He would go on and
on about how he was not happy with the hospital or the staff. Nothing
was as good as where he came from. He did this right from the start.
We changed so many things for him. He would take it out on the
patients too. For example a man started coughing while he was being
sewn up at the end of his operation. Dr Lucas refused to put him back to
sleep.”
The named surgeon in this incident advised the investigation team that “Dr
Lucas never allowed any of my patients to wake up prior to the completion
of suturing”.
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