Medico-legal Aspects of Anaesthetic Practice

1. Medico-legal Aspects of Anaesthetic Practice 10 November 2011 Dr Udvitha Nandasoma Medico-Legal Adviser

2. Who decides a doctor’s accountability after a clinical incident?

4. Anaesthetic claims (private practice) • Claims within the speciality are relatively uncommon • Members expect to be notified of one claim every 35 years, compared to: 1 in 15 yrs – ophthalmology 1 in 8 yrs – orthopaedics • Not all settled as majority notified to MDU are successfully defended or discontinued by claimant

5. Recurring themes • 10 yr period – 130 claims [settled, discontinued or active] • Majority – Dental damage [>50% notifications] – average compensation £1500 for those cases that settled (largest>£10,000) • Death or brain damage, anaesthetic awareness, needle misplacement [approx 10%] – average compensation £100,000 (largest >£2m) • Figures exclude legal costs • For smaller payouts, legal costs can exceed award itself

6. Awareness and inadequate analgesia • ‘Awareness’ = range of experiences [bad dreams, vague but painless recollections, paralysed but not anaesthetised] • Small number of notified claims/rare • Minority settled • Claims arise regardless of technique • Balanced anaesthesia with relaxant & inhalational agent • Total iv anaesthesia • Misunderstanding/unrealistic expectations • Notes recorded clearly = concerns easier to resolve

7. Complaints 2011 • 54 complaint files opened in first 10 months of 2011 Pain clinic 6 ICU/ HDU 3 Recognized complication 22 Attitude 4 Awareness/ Inadequacy 5 Assault 1 Other 8 Preassessment 5

8. WRONG SITE SURGERY • MDU notified of 63 cases since 2000 • 4 Related to anaesthesia

9. How is this relevant to Preassessment? • Consent • Communication • With colleagues • Managing patient expectations • Continuity of care

10. Consent • Person conducting procedure is responsible for ensuring that the patient has been given enough time and information to make an informed decision, and has given their consent. • Seeking consent can be delegated to an appropriately qualified person. GMC Consent: patients and doctors making decisions together 2009 Paragraphs 26 and 27

11. Scope of Consent • Do you anticipate that other interventions might be required • Does the consent process adequately reflect the range of practice the patient might experience

12. Communication with Colleagues • Is there understanding of the patient factors that might need further consideration • Anticoagulation • Medical –Comorbidity • Prescribed Medication • Do you have agreed ways of working where appropriate

13. Communication with patients • Managing patient expectations • Type of anesthesia • What sensations/ noises might they be aware of • Likely experience of post operative pain

14. Specific Issues

15. Dental Damage Risk Management: • Assess upper airway/dentition etc prior to anaesthetic • Clear documentation especially of poor dentition • Record warnings given to patient

16. Oral and airway damage • Soft tissue structures of • Oropharynx • Nasopharynx • trachea • 3 cases notified in 10 year period involving a Laryngoscope/Laryngeal mask • Sore mouth/throat immediately post-op • Recorded warnings may assist if claim brought at a later date

17. Drug reactions and errors • this few claims from drug errors or adverse reactions • 7 notifications (3 resulting in claim) in 10 year period • 2 settled – drug administered to patient with allergy • IV drugs through misplaced cannula causing local damage to surrounding tissue

18. Death and brain damage • 4 claims settled in 10 year period • All GA where patient suffered cardiac arrest or CVA • Unique facts in each case • Patients need to be offered relevant information in order to provide informed consent • GMC guidance – patients must be given information re risks and benefits and have their questions answered fully (Consent 2008, para 9)

19. Aspiration • Very few claims • Large award as patient needed life long care • Presence of small bowel obstruction • If specific steps are taken to minimise aspiration this should be documented

20. Positioning and pressure injuries • Risks to patients sustaining pressure damage/nerve palsies • Small number of settled claims due to damage from application of prolonged pressure by a piece of equipment • Difficult to defend allegations of negligence successfully • Make a written record of all the steps taken to protect the patient from harm • Document any particular techniques employed

21. Needle misplacement • 10 claims, 4 settled in 10 year period • 3 settled – regional anaesthetic administered to wrong side prior to limb surgery • Modest compensation unless nerve injury • Patient Safety Alert: WHO Surgical Safety Checklist, NPSA, 26/1/2009 [npsa.nhs.uk] • 4 claims re spinal and epidural alleged nerve damage (1 successful, 3 discontinued) • Clear details re risks were given to patients

22. Learning lessons • Are there areas where you see your preassessment system not working as well as it should? • Adverse incidents do occur: recognise risks and reflect on ways to reduce the possibility of an error • Effective Adverse Incident Reporting • Departmental Audit • Identify ongoing systemic risks • Develop risk management procedures • Contact MDO for advice

23. Managing risk 1 • Discussion prior to anaesthetic • Why treatment is necessary • Risks involved • alternatives • Record warnings given pre-op • Post op sore throat • Awareness during sedation • Discuss risks specific to that individual if appropriate

24. Managing risk 2 • Develop a routine for pre & post-op assessments • Check PMSHx, allergies, concurrent medications before prescribing new drugs • Document you have checked pressure points and ensure those assisting are aware of risks • Procedures in place to eliminate risk of ‘wrong side’ errors – check records, confirm with patient • If something goes wrong – full explanation, apology [GMC guidance]

25. Any Questions?