Health Service Commissioner : first report for session 1982/83 : selected investigations completed April- September 1982.

  • Great Britain. Health Service Commissioner.
Date:
1983
Catalogue details

Licence: Open Government Licence

Credit: Health Service Commissioner : first report for session 1982/83 : selected investigations completed April- September 1982. Source: Wellcome Collection.

    12/192 page 10
    12. The anaesthetic registrar said that it was not unusual in the event of an emergency caesarean section for the anaesthetist not to see the patient before her arrival in theatre. When a surgeon telephoned to make arrange- ments for an anaesthetist the latter normally asked whether there were any known problems but he could not remember being told that there were any with the complainant. The anaesthetic registrar’s recollection was that he first heard of her previous difficulty from the patient herself when he went to the theatre and had a routine talk with her about her anaesthetic history. He was quite certain that she told him merely that she was difficult to intubate on a previous occasion but made no mention of the ENT consultation and its outcome. He examined the complainant and there was no visible abnormalities. Only her obstetric notes were in the theatre and the anaes- thetic registrar was subsequently surprised to learn of the existence of other notes. 13. The anaesthetic registrar said that although the detailed anaesthetic history was the province of the anaesthetist any serious pre-existing medical condition might have emerged at the ante-natal clinic. He made the point that the obstetrician had overall responsibility for the patient and all aspects of her well-being. He agreed that, from his point of view, it would have been better had all the information been available because although the same anaesthetic route might have been chosen he could have called in the assistance of a senior registrar from the outset. And he made the additional point that as there was no evidence of major problems it was reasonable to proceed with the intubation, and this was a matter for his clinical judgment. In the event it was only after he encountered difficulty in trying to intubate the patient that he summoned the help of a senior registrar in anaesthetics. 14. The senior registrar in anaesthetics said that he was summoned to the theatre when he was attending a meeting at the sister hospital. He said that when he arrived there was not time to read the medical notes and he decided to make a further attempt at intubation. He explained that his decision was not a hurried one and took into account the bleeding which had resulted from the previous unsuccessful attempt at intubating the complainant. He succeeded in intubating the patient and nothing untoward subsequently occurred as a result of his action. He said that with hindsight he would make the same decision to intubate again. Findings 15. On the balance of probability I think that the previous medical notes were available in the ante-natal clinic in February 1979. The opportunity to transfer relevant information contained in them to the obstetric notes was missed by both the midwifery staff and the SHO on that occasion. The progress of the complainant’s pregnancy did not prompt the medical or nursing staff to call for the earlier notes again while she attended the ante- natal clinic. Both the SHO and his consultant made the point that a patient’s anaesthetic history would not be a matter of concern to the obstetricians. But if, as I have been informed, it 1s not unusual for the first meeting between an anaesthetic registrar and a patient requiring a caesarian section to be in the
    digitised image 1
    digitised image 2
    digitised image 3