Gisborne Hospital Report - Health and Disability Commissioner

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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
Gisborne Hospital 1999 – 2000 Operating Theatre Protocols 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 technicians in theatre and confirmed in conversation today by nursing staff.” 4.3 There appear to be no incident reports specifically relating to the throwing of sharps. Incident summaries, not written on the official THL incident form, record the circumstances at the time of the syringe throwing incident but do not specifically mention syringe throwing. There is no evidence to indicate whether or not these summaries were given to management. 4.4 Four anaesthetic technicians described their experiences in relation to this allegation. The first stated that Dr Lucas did not “misbehave such as by throwing things in theatre”. The second technician reported seeing Dr Lucas throw an IV cannula across the room on more than one occasion. Other people were present when Dr Lucas threw the cannula but the second technician could not remember who they were. “I was the only one in the room when he threw a 22 gauge needle from one corner of the room to the other. It was a bloody needle. On another occasion he threw a 20 gauge needle onto the floor because he couldn’t get it in the vein.” This technician described Dr Lucas’ behaviour as a temper tantrum. “He would pick up a tray and throw it on the floor if he did not like its position.” According to this technician, Dr Lucas acted like this from the beginning of his time at Tairawhiti Healthcare. 4.5 The third anaesthetic technician saw Dr Lucas throw cannulas. The technician observed that: “Dr Lucas would get agitated if things didn’t go right. If he could not insert a cannula on the first attempt the cannula would go flying. I observed this on one occasion. Dr Lucas was trying to insert a cannula and couldn’t the first time. The patient was still awake and Dr Lucas pulled the cannula out. There was a sharps bucket in theatre and Dr Lucas threw the cannula towards the sharps bucket but it ended up on the floor. Dr Lucas walked over to the trolley to get another cannula. I cleaned up the mess on the floor. I heard that Dr Lucas did not like objects on top of the anaesthetic machine and would throw them off. While I did not observe this, a colleague did.” 4.6 The fourth technician did not see Dr Lucas throw sharps. He saw him toss a sharp half a metre on to an anaesthetic tray, “but it was tossing not throwing”. The technician would not expect other anaesthetists to toss sharps and he has not seen other anaesthetists do so at Gisborne Hospital, but he commented that “people get stressed and do not always behave by the rule book”. 4.7 A nurse reported that she saw Dr Lucas throwing sharps in theatre. She reported that Dr Lucas became very frustrated when treating a badly hurt child. He could not get a line into the child’s arm. “He threw a sharp across the room. I didn’t think his action was justified. He threw the sharp away to the corner of the room and not into the sharp receptacle which was situated behind him.” 84
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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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Gisborne Hospital 1999 - 2000 Patie
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RECOMMENDATIONS Quality Assurance S
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Gisborne Hospital 1999 - 2000 Recom
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Gisborne Hospital 1999 - 2000 Recom
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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