Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
3.39 Re-use of anaesthetic syringes is not a practice that “minimises potential
harm” to patients on whom a syringe is re-used. As noted by my anaesthetic
advisor, re-use of syringes “poses a risk to patients”. Although the risk of
infection may be minimal, it is nonetheless real, as was acknowledged by
Tairawhiti Healthcare’s appropriate decision, in June 2000, to implement a
“look back” programme and contact 134 Gisborne Hospital patients on whom
Dr Lucas may have re-used syringes.
3.40 It is no answer to a claim that patient safety is compromised by the re-use of
single-use medical devices to say that the minimal risk to the individual
patients is outweighed by the overall benefit to patients (more of whom may
be treated if scarce health resources are “stretched” by re-use). I do not accept
that the patient safety standard of “minimal potential harm”, affirmed in Right
4(4) as an individual right, should be watered down. In my opinion, even if a
utilitarian approach is adopted, there is likely to be an overall dis-benefit to
patients if clinicians compromise safety for individual patients in the hope of
maximising benefit for the community of patients.
3.41 I endorse the following helpful statement from the Medical Practitioners
Disciplinary Tribunal in Re White (Decision No. 69/98/36C, 30 April 1999):
“The prevention of infection and cross infection is fundamental to basic
medical practice. Patients have a right to be confident, during
examinations and other medical and surgical procedures, that they are
not unnecessarily exposed to the risk of infection. For any medical
person trained in sterile techniques and aware of the problems of
transmission of infection to deliberately disregard this training and
information, is, in our view, simply repugnant. Regard must be had for a
patient’s safety and well-being. This is fundamental to the contract
between a patient and a doctor. That relationship must be based on the
patient’s expectation that the doctor will try to do his or her best for the
patient under all circumstances.”
3.42 In my opinion, by his admitted re-use of anaesthetic syringes, Dr Lucas failed
to provide services in a manner that minimised potential harm to his patients
and thereby breached Right 4(4) of the Code.
4. THROWING SYRINGES AND BLOODY NEEDLES
The alleged incidents
4.1 Dr Lucas was alleged to have breached consumers’ rights to services of an
appropriate standard by throwing syringes and bloody needles in theatre,
rather than attempting to place them in the receptacle provided.
4.2 The NZNO memorandum dated 14 June 2000, which was sent to the Minister
of Health and contributed to my decision to inquire into events at Gisborne
Hospital, noted that:
“Nurses from other areas (notably ICU) report to me that the anaesthetist
[Dr Lucas] was in the habit of throwing sharps – ie, syringes and bloody
83