Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
5.4 The technicians, nurses and midwives objected to Dr Lucas departing from the
practice of lifting the theatre gowns. Cutting the gown was perceived as
unnecessary and revealed more of the patient’s body than was thought
necessary. Respect for dignity appears to have been the reason why pre-slit
operating gowns were not used at Gisborne Hospital. The midwives were
opposed to their use.
5.5 An incident form dated 23 December 1999, referring to the general practice of
cutting gowns, records an incident where a maternity patient had her gown cut
by Dr Lucas. There is no recorded outcome for the incident form dated 23
December 1999 and no official “reply” or evidence of an investigation was
received by the Manager of Maternity Services.
5.6 No complaints about the cutting of gowns were ever received from patients.
5.7 Concerns were raised with the Group Manager (Hospital), and he met with
maternity staff, and later with Dr Lucas. THL stated that following these
meetings the issue was resolved.
Dr Lucas’ explanation
5.8 Dr Lucas stated: “This whole issue [cutting and ripping of gowns] had been
the subject of an incident report and had been discussed with Mr Madden, long
before I returned to Canada.”
5.9 Dr Lucas noted that patients needing Caesarean sections wore long mid-calf
length gowns that did not open at the back:
“These gowns interfered with theatre preparations of the patient
including placement of ECG electrodes, and administration and
subsequent testing of regional anaesthesia. Trying to move these full
length gowns out of the way was at best uncomfortable for the patient
and at worst not safe as the theatre tables are quite narrow. Furthermore,
struggling with gowns was an inefficient and unnecessary consumption
of theatre time. All other patients arrive in theatre in the standard theatre
gown which is specially designed for safety and efficiency with opening
back and arms.”
5.10 Dr Lucas preferred the traditional back-opening gowns. He considered these
were less disruptive to the patients as they provided better spinal access. Dr
Lucas advised that “theatre gowns in theatre are such a basic given”.
5.11 Dr Lucas asked the midwives to send patients to the theatre with the usual
theatre gowns that all other patients have worn for decades. He also went to
the obstetric ward and expressed his preference to the Charge Midwife.
5.12 When Dr Lucas’ request to the midwives did not work he simply cut the gown
at the back “rather than jostling and bustling the pregnant ladies who really
resent moving when they are in late pregnancy – the less moving the better”.
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