09HDC01565 - Health and Disability Commissioner

Health and Disability Commissioner
He states that this care does not need to be in the ICU, but the ward area/SCU
needs to be properly equipped.
Further information from Dr H
Anaesthetist Dr H informed the Coroner that he reviewed his management of Mr A‘s
care with a senior neuroanaesthetist and with the Director of the Acute Pain
Management Service, and presented his management for peer review at the
Department of Anaesthesia Mortality and Morbidity Review. Dr H contacted
colleagues in Sydney and London to establish whether they were aware of
unexplained deaths following surgery for Chiari 1 malformations (they were not). He
also conducted a literature review and sought information from the American Society
of Anaesthesiologists (ASA) Closed Claims Project. The ASA states: ―A search of the
ASA Closed Claims Project database has no similar cases of Arnold Chiari
Malformation and postoperative respiratory arrest yielded two claims in which
patients with this condition sustained postoperative respiratory arrest. Neither patient
was undergoing surgical correction of their malformation when the event occurred.
Both events occurred in the early 1990s.‖
Dr H provided the Coroner with details of further action he has taken in light of Mr
A‘s death. This includes confirming that appropriate education strategies are available
for the ward‘s nursing staff, and offering to take an education session on the ward
with a particular focus on PCA devices. He states he has reiterated that:
in addition to sedation scores, monitoring of respiratory rate is important where
PCAs are used, and particularly for neurosurgical patients; and
that the clinical monitoring of patients by nursing staff is the lynchpin of patient
safety in the clinical environment.
5 September 2012 68
Names have been removed (except Canterbury DHB and the experts who advised on this case) to
protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the
person’s actual name.