Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
opened to allow application of ECG electrodes or administration of spinal or
epidural anaesthesia.”
5.19 THL has no documented policy on the use of gowns.
Opinion
5.20 I accept the advice of my expert clinical advisors that access to a patient’s
lower back for spinal anaesthesia is essential for good practice. Although, to a
lay person, the notion that the anaesthetist might cut or rip open the back of a
theatre gown is surprising, I accept that Dr Lucas’ decision to cut gowns open,
and his manner of doing so, was consistent with professional standards. I note
in passing that no patient who ever experienced Dr Lucas cutting the back of
her gown in theatre made a complaint. Whatever the disquiet of some of Dr
Lucas’ colleagues, who were concerned about patient dignity, the patients
themselves do not appear to have voiced any concerns.
5.21 Accordingly, in my opinion Dr Lucas did not breach Right 4(2) of the Code in
relation to this matter.
6. INAPPROPRIATE USE OF ICE
The alleged incidents
6.1 The manner in which Dr Lucas used ice to check the level of anaesthetic block
was alleged to have been inappropriate. In particular, it was alleged that ice
cubes were rubbed over women’s nipples until the cubes melted and until after
the patients had confirmed they had no feeling above the relevant area.
6.2 The investigation team gathered first-hand evidence of Dr Lucas’ use of ice
from two nurses, four anaesthetic technicians, a surgeon and a patient. Apart
from one nurse, those who recorded incidents in writing relating to Dr Lucas’
use of ice had not personally seen him using ice, but were recording concerns
they had heard from witnesses.
6.3 An anaesthetic technician reported to the investigation team what she had seen
in relation to a patient who was having an epidural steroid:
“The patient was on her back, and had already been given the epidural
steroid. The patient had a gown on and Dr Lucas started rubbing ice
down the patient’s side to the groin area and he did it over and over.
[The anaesthetic technician] went and got another technician, to see what
the other technician thought of it, because [she] had never seen ice used
in this way before. The other technician had seen ice used before, but
not to that extent. The epidural steroid patient had had back and leg pain
and she had received an injection of corticoid steroid. Dr Lucas
explained that he was checking how far the epidural block had gone up.
[The technician] was concerned about the length of time that it took Dr
Lucas to test the epidural block with the ice because the patient was
getting cold and Dr Lucas only did one side with the ice. Dr Lucas went
down the left side of the patient, down the side of the nipple, down to the
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