Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
Ensuring that the patient remains in the recovery facility until safe for
discharge to a ward. Where transfer to an intensive care unit or high
dependency unit is necessary, responsibility for care remains with the
anaesthetist until this transfer is complete.
2.4 Ensuring that there will be adequate post-operative care of the
patient after discharge from the recovery area.”
14.15 I received the following advice from my expert anaesthetist:
“Except in case of emergency, as when a cardiac arrest has occurred, the
anaesthetist should never leave an anaesthetised patient in theatre in the
care of anyone other than another anaesthetist and then only after a
handover. In such circumstances it would be more usual for the second
anaesthetist to attend the emergency.
The cause of post partum haemorrhage is usually managed by surgical
staff although if they were not contactable the anaesthetist would be
expected to advise on management. Until such time as ‘definitive’
treatment of the cause was possible the anaesthetist would be expected to
ensure cardiovascular stability. In the scenario described either the
medicines chart would need to be taken to the theatre for the anaesthetist
to prescribe treatment, or a verbal order would have to be accepted by
the recovery nurse.
The description of ‘football’ sized clots is questionable.
Once again the case illustrates the antipathy that appears to have existed
between Dr Lucas and nursing staff.”
Opinion
14.16 I am satisfied, on the basis of the expert anaesthetic advice that I have
received, that Dr Lucas did not inappropriately refuse to attend a patient in
recovery following a Caesarean section. In my opinion Dr Lucas complied
with professional standards and did not breach Right 4(2) of the Code.
15. INCIDENT REPORTING
15.1 For general comments on incident reporting, and the handling of incidents
not relating to Dr Lucas, see chapter 3.
15.2 Theatre incident reports were channelled through the Theatre Manager using
the hospital’s standard incident form. There was no designated place in the
Theatre Manager’s office to place a completed form. A number of forms
were lost. Witnesses saw incident forms completed and handed in but the
Theatre Manager, Group Manager (Hospital) and Quality Co-ordinator
subsequently had no record of receiving these forms. Other incident forms
were received but were ignored or remained unresolved.
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