Gisborne Hospital Report - Health and Disability Commissioner

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NZNO INTERNAL MEMORANDUM 1 JUNE 2000 In an internal NZNO memorandum dated 1 June 2000 to Ms Brenda Wilson, Chief Executive Officer, and Mr James Ritchie, NZNO Area Manager (Northern), Ms Gwenda Brodie, NZNO regional representative, stated: “Further to our telephone discussions today and previously. Facts that have emerged in respect of this matter are as follows: 1. The anaesthetist in question (Dr Brian Lucas of Canada) has admitted re-using syringes. 2. Two staff at least witnessed directly the practice on separate occasions. Both staff (1 anaesthetic tech, 1 Staff Nurse – NZNO delegate Jo Garrett) completed incident forms and drew the matter to the attention of the anaesthetist, the head anaesthetic technician and the Theatre Manager. 3. The Theatre Manager (NZNO member Helen Stephenson) completed incident forms also and reported the matter immediately to the General Manager Hospital Group (Dan Madden). She also spoke to the anaesthetist and used a packaged syringe to draw his attention to the words ‘for single use only’ on the packaging. The HAT [Head Anaesthetic Technician] reported the matter to the Head of Anaesthetics (Dr James Carstens). 4. The first incident report was forwarded in October 1999. It seems this incident form has been lost. 5. The Theatre Manager completed a second incident form early in November 1999 referring to the first form and noting no action had yet been taken. 6. The Theatre Manager was told by various unspecified medical staff to stop filling out incident forms and put up with the anaesthetist because ‘we need him’. One person giving this advice was the Medical Director of the Surgical Service at the time, Dr Ian Burton. 7. Dr Burton also instructed the Theatre Manager to apologise to the anaesthetist, apparently for criticising his practice. (The Theatre Manager did not apologise.) 8. The re-use practice apparently stopped for a short time but recommenced. Nurses who gave evidence today said they had noted that if any of them challenged him/disagreed with his practices/advocated for patients the anaesthetist reacted by aggressively responding and on more than one occasion waking women patients early – while they were still being sewn up and still in lithotomy. 9. Incident forms were completed on every occasion these things happened and actioned promptly by the Theatre Manager. 10. Nurses from other areas (notably ICU) report to me that the anaesthetist was in the habit of throwing sharps – ie syringes and bloody needles – at random when events did not go smoothly. I have not yet ascertained whether he aimed at people or just tossed at random. This behaviour was also reported by anaesthetic techs in theatre and confirmed in conversation today by nursing staff. 187
11. The anaesthetist had a practice of ripping or cutting gowns off patients, invariably women. He also used a technique to ascertain the level of block established. This method consisted of rubbing ice cubes all over women’s breasts for a considerable period of time. Nursing staff and anaesthetic techs found this practice excessive and offensive. They were told it was accepted practice. 12. The anaesthetist claimed thick leather straps were essential to secure patients to the operating table. The Theatre Manager refused to order these items and the anaesthetist responded by tipping the table so women, especially Caesarean section women having epidurals, had to cling tightly to the table to stop sliding off. All the surgeons approached the Theatre Manager individually to urge the purchase of the straps until the anaesthetist departed. Since then there have been no requests for straps. 13. 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.) 14. One nurse described an incident where a patient was haemorrhaging post partum in recovery. The anaesthetist refused to come and see the patient or to give written orders for medication. The nurse refused to administer meds and called a surgeon from a ward. When the surgeon arrived the anaesthetist accused the nurse of not giving the necessary meds. (Incident form completed and actioned promptly.) 15. The same nurse described the anaesthetist’s consistent refusal to document and chart medication. His practice was to write medication instructions on the anaesthetic sheet and presume this would be actioned in the ward (didn’t happen). She testified that he became aggressive and threatening when challenged. 16. A nurse also described the anaesthetist’s common practice of telling patients he would prove they were not allergic to meds they had reported reacting to. At least once a nurse who was being anaesthetised was put under crying in fear because he allowed her to believe he had given her the drug she was allergic to. Only after she was asleep did he tell theatre staff he had not given the drug. Intentions stated today during and after the interviews with the nurses included an external review of the anaesthetic dept and possibly theatre ‘down the track, mediumterm’. When pressed hard by myself and the PSA organiser, Dan Madden agreed to meet staff to discuss other issues not specifically to do with the re-use of syringes. In conversation with me between interviews he referred to this as ‘closure’ and I have the strong impression there is no intent to properly investigate or engender outcomes from the other matters. I have pinned him to 20 June 00 as I will be in Gisborne on leave then and can support members. (It occurs to me it would be useful if Margaret Cain could also be present if she is available.) Both Dan Madden and Dr Bruce Duncan (Director Public Health Unit, these two did the interviews) informed me there was only the tiniest risk to patients because of the process used to administer anaesthesia. They appeared reluctant to notify patients but eventually admitted there was an intent to do so. The process for identifying patients is still not clear and a teleconference with the HFA and the Ministry was to be held today (1 June 00) in respect to the identification 188
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GISBORNE HOSPITAL 1999 - 2000 A rep
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Table of Contents Page Executive Su
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1. BACKGROUND EXECUTIVE SUMMARY 1.1
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3. THE ENVIRONMENT 3.1 My investiga
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pathologist, staff shortages and pr
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Gisborne Hospital 1999 - 2000 Intro
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Chapter 2 Quality Assurance Systems
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Gisborne Hospital 1999 - 2000 Quali
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Page 145 and 146: Gisborne Hospital 1999 - 2000 PSA T
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Page 189 and 190: RECOMMENDATIONS Quality Assurance S
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Page 201: GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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