Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
Reporting of staff concerns and initial management action
3.11 In the first week of Dr Lucas’ employment a dental list went over time. Dr
Lucas thought the fault lay with an anaesthetic technician because she had
been throwing out his used syringes. The anaesthetic technician mentioned the
incident to the Charge Anaesthetic Technician and reported filling out an
incident form about the re-use of syringes. A witness saw the technician fill
out an incident form and hand it in, but the form was apparently lost. Some
senior clinicians and managers questioned whether the incident form was
handed in.
3.12 The Charge Anaesthetic Technician informed the Theatre Manager in October
1999 on the Manager’s return from leave that Dr Lucas was re-using “single
use” syringes. The Theatre Manager, who was on leave, when Dr Lucas
started work, informed the Group Manager (Hospital) about the re-use of
syringes issue in writing. She also reported speaking to the Quality Coordinator
about her concerns.
3.13 Within the first few weeks of Dr Lucas’ employment the Head of Department
(Anaesthesia) was told by the Theatre Manager that Dr Lucas was re-using
syringes. The Head of Department took Dr Lucas aside and told him “it was
an absolute no-no”. He also spoke to the Group Manager (Hospital) about the
re-use incident and told him that he had spoken to Dr Lucas.
3.14 It appears the Head of Department (Anaesthesia) acted in response to the
incident in October, despite the fact that the incident form was lost. The Head
of Department believed that Dr Lucas had ceased his practice of re-using
syringes. He was very upset when he discovered that Dr Lucas later disobeyed
his specific instructions.
3.15 A further incident form relating to the re-use of syringes was completed by the
Theatre Manager in November. This form is undated but was registered in the
incident reporting system on 26 November 1999.
3.16 The Quality Co-ordinator received this report and sent it within 24 hours to the
Group Manager (Hospital) and the Clinical Director (Surgery). She was not
aware that there had been an earlier report in October about this issue, because
that report was mislaid and so never reached her office. After the incident was
brought to their attention, the Group Manager (Hospital) and the Clinical
Director (Surgery) discussed the matter.
3.17 The Clinical Director (Surgery) delegated the matter to the Head of
Department (Anaesthesia) because he was concerned that Dr Lucas was close
to leaving due to the criticisms levelled at him and thought that his
involvement might precipitate a resignation. He was concerned at the
possibility of losing Dr Lucas with the approaching millennium. In his view
“the issue of re-use of syringes was about anaesthetic technique”. Dr Lucas
responded that he did not consider resigning and gave no indication that he
would do so.
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