Death in the theatre – Part III

When death occurs in theatre during a medical operation, it is an extremely distressing experience for the surgeon and the anesthetist. The surgeon and anesthetist’s duty of care owed to the patient comes under strict scrutiny.

This is what happened when Stella, a mother of two, died in theatre during a Caesarean section operation. The family of the deceased took the obstetrician, the anesthetist and the Attorney General to the civil division of the High Court for medical negligence.

The anesthetist testified in court that the patient’s consent to the operation was sought and was on record.

The judge’s questions

However, to the judge, what was not clear was whether the patient was fully apprised of all available options and their associated merits and disaantages.

In other words, was the patient providing consent from an informed position, that is giving an informed consent, or was she merely agreeing to the doctor’s suggestions without fully comprehending the implications of their proposals and the possible consequences on her life?

The judge raised a number of issues regarding the consent the patient is purported to have given and some of the issues raised were as follows

• What exactly was explained and discussed with the patient and her spouse with regard to performing a Caesarean Section operation in the first place?

• Were the Non-EmergencyElective and Emergency types of Caesarean Section described and explained to the patient and the difference between the two explained? And what level of understanding did the client show?

• What were the details of the available options of anesthesia that were actually explained to the patient? What aantages and disaantages were presented to the patient for each of the available options? And what limitations of these options were pointed out to the patient prior to the operation?

• What measures were taken to check and cross-check that the patient fully understood the implications of the proposed procedures? Which nursemidwife was present and in attendance as the explanations were being given to the client? Was the spouse also counselled and probed whether he really understood the merits and demerits of the options?

• Where was the record of the signed form of informed consent to the operation by the patient and evidence that it was witnessed by a competent authority?

• What role did the obstetrician play in enlightening the patient on the proposed operation and anesthesia options and the attendant risks associated?

Court could not find answers to these questions in the records of the deceased and had no alternative but to believe that the operation, which was admittedly a major one, was taken very lightly by the medical personnel and no adequate preparations were made prior to the same.

The legal position in such cases is that the patient should be aised on material risks, and a material risk is one to which a reasonable person in the patient’s position is likely to attach significance, or those to which the doctor knows or ought to know the particular patient is likely to attach significance.

The answers

These issues raise a fundamental question realistically, how much information should the doctor and anesthetist have given the deceased? From an academic point of view, the answers are

• That amount of information which enables the patient to understand the nature and purpose of the proposed course of action which, if consented to, will provide the health workers with a sufficient defense in a court of law.

• The amount of information which enables the patient to make a properly informed choice of the kind, which if the information is not provided, might be considered negligence in a court of law.

The anesthetist did not make matters any easier in court when he stated that he administered three bottles of fluid to the patient during the operation. Yet records available state that the anesthetist found the patient already in theatre at about 4pm and the patient had a cardiac arrest at 4.17pm.

To the judge, there seems to have been no time for the anesthetist to administer the three bottles of saline solution in the course of the operation. In fact, court’s opinion was that there was no time even for one bottle.

There were also no records to show that the anesthetist preloaded the patient with fluids before the onset of the operation, a measure the judge considered vital to avoid hypotension.

More concerns

Another of the judge’s concern was that in an operation where spinal anesthesia was being applied, the anesthetist should have had his hands more freely available and be better able to efficiently and effectively monitor the vital signs and functions of the patient. Evidence given in court indicated that the anesthetist realised the patient had no pulse after the surgeons informed him that the patient’s blood was dark.

There was no record of the anesthetist showing details of the monitoring of the patient’s state of alertness and of being fully awake, breathing movements, words expressed and exchanged with the patient during the operation, probing questions of the anesthetist to engage the patient and continuously assess the patient’s alertness, state of well-being, vital signs and functions during the operation.

Given the lack of detail on the vital signs and parameters that were being monitored during the operation, court expected the anesthetist to give an explanation as to why he failed to carry out this critical function. Court considered this a laxity of gigantic proportions.

The ruling

The judge, therefore, found that Stella died of culpable negligence and her death was an avoidable one, because the patient did not make the fullest possible use of all available professional medical services and support.

To the judge, there were serious shortcomings present, lapses, acts of omission and commission exhibited during and in the provision of care, and a serious breakdown in patient care, which could have been avoided and thereby change the course of the events in the process that led to Stella’s death.

The judge awarded the family more than Shs120 million, with interest of 25 per cent per annum on the general damages from the date of death until payment in full.

The writer is consultant Forensic Pathologist.


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