Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
7 December 1999 Incident report reviewed by Clinical
Director (Surgery)
16 March 2000 Northland issue reported on TVOne news
17 March 2000 Northland issue reported in NZ Herald
17 March 2000 E-mail from Northland CEO re “anaesthetic
issue” (this alluded to previous media story):
“We have a problem with one of our
anaesthetists. My initial enquiries have
disclosed some interesting facts which I am
told are common practices in this country.
No-one counter checks …. Although many
things are counted and recounted in theatre,
syringes are not.”
CEO e-mail query to Theatre Manager,
Clinical Director (Surgery) and Hospital
Manager re “What is our practice? Do we
have a similar risk?”
Clinical Director (Surgery) e-mail to CEO
“We have recently had a minor problem
with a locum anaesthetist but it was very
rapidly dealt with and so I don’t think we
have anything to be concerned about.”
26 March 2000 Dr Lucas’ employment ceased
1 May 2000 Northland patient notification date
9 May 2000 CEO advised that Dr Lucas had re-used
syringes
9 May 2000 File note, Chapman Tripp contacted
17 May 2000 Audit Committee briefed
23 May 2000 Legal advice provided by e-mail
23 May 2000 Board of Directors briefed at meeting.
Dr Lucas’ explanation
3.5 Dr Lucas described his practice as follows:
“My practice was to refill the rather expensive propofol and rocuronium
syringes and re-use them. The injection site I would use was either of
the two on the administration IV set. The type of intravenous cannula
that is used at Gisborne has an injection site integral to the cannula but I
preferred not to use that one, its being too close to the patient. Within a
week (perhaps two) of starting, Dr Carstens approached me and told me
that the practice was considered substandard at Gisborne. I subsequently
stopped the practice with only very rare subsequent lapses as I changed
my habit after 26 years of practice in Canada.”
3.6 Dr Bruce Duncan, as acting Medical Director and then Clinical Director
(Public Health), who investigated Dr Lucas’ practice of re-use in May 2000
for THL, summarised a telephone call with Dr Lucas. The following is an
excerpt from an agreed summary of that telephone conversation:
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