Transcript Slide 1

Medico-legal Aspects of
Anaesthetic Practice
10 November 2011
Dr Udvitha Nandasoma
Medico-Legal Adviser
Who decides a doctor’s accountability
after a clinical incident?
Criminal Hearing
Criminal conviction if
found guilty
NHS Trust
Investigation
NHS Complaints
Procedure
Disciplinary investigation
Local resolution
Maintaining High
Professional Standards
Health Service
Ombudsman
GMC
Coroner’s inquest
Fitness to practice hearing
Verdict on death
Restrictions on practice or
erasure from medical
register
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Claims notifications over 10 years
Dental damage
8%
4%
2%
Oral/airway damage
Awareness
11%
Drug reaction
5%
58%
9%
Death/Brain damage
Aspiration
3%
Pressure/positioning
Needle misplacement
© 2011 MDU Services Limited
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
© 2011 MDU Services Limited
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
© 2011 MDU Services Limited
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
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Complaints 2011
 54 complaint files opened in first 10 months of 2011
Pain clinic
ICU/ HDU
Recognized complication
Attitude
Awareness/ Inadequacy
Assault
Other
Preassessment
6
3
22
4
5
1
8
5
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WRONG SITE SURGERY
 MDU notified of 63 cases since 2000
 4 Related to anaesthesia
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How is this relevant to
Preassessment?
 Consent
 Communication
– With colleagues
– Managing patient expectations
 Continuity of care
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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
© 2011 MDU Services Limited
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
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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
© 2011 MDU Services Limited
Communication with patients
 Managing patient expectations
– Type of anesthesia
– What sensations/ noises might they be aware of
– Likely experience of post operative pain
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Specific Issues
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Dental Damage
Risk Management:
 Assess upper airway/dentition etc prior to anaesthetic
 Clear documentation especially of poor dentition
 Record warnings given to patient
© 2011 MDU Services Limited
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
© 2011 MDU Services Limited
Drug reactions and errors
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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
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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)
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Aspiration
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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
© 2011 MDU Services Limited
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
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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
© 2011 MDU Services Limited
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
© 2011 MDU Services Limited
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
© 2011 MDU Services Limited
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]
© 2011 MDU Services Limited
Any Questions?
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