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Woman 47 died after she was given too much anaesthetic by mistake coroner
03/09/2024
A coroner has warned that a common way of giving anaesthetic to patients poses a risk of future deaths, after a woman was administered too much local anaesthetic by mistake and died three months later.
Dr Rachel Gibson, who had severe osteoarthritis, had hip replacement surgery at Spire Lea Hospital in Cambridge on April 12, 2022, according to a coroner’s report.
Philip Barlow, assistant coroner for Cambridgeshire and Peterborough, said in the report that 47-year-old Dr Gibson was given a local anaesthetic towards the end of her procedure.
He said that the amount of the anaesthetic, Ropivacaine, was “in excess of the recommended dose”.
Dr Gibson suffered an unwitnessed cardiac arrest after returning to her room.
She was resuscitated and transferred to Addenbrooke’s Hospital in Cambridge where she was found to have sustained irreversible brain damage.
She died at Addenbrooke’s Hospital on July 14 2022.
“The evidence was that it is routine practice before the procedure for the anaesthetist to give oral instructions to the scrub nurse specifying the type and dose of local anaesthetic to be used to infiltrate the operation site,” the coroner said.
“Towards the end of the operation the scrub nurse hands the local anaesthetic to the surgeon who then carries out the infiltration.
“The intention in this case was for a 2% solution of Ropivacaine to be diluted 50/50 with normal saline before it was infiltrated.
“The evidence suggested that this was not done.
“The result was that excessive Ropivacaine was administered by mistake.
“The evidence at the inquest was that this type of practice is common nationally.”
He said he was writing to the President of Royal College of Anaesthetists with his concern that there was a “risk that future deaths could occur unless action is taken”.
He said that the “responsibility for checking and administering the local anaesthetic is unclear”.
He said that the instruction was “given orally and not written down by the anaesthetist (the prescriber)”.
“There is inconsistency in the way the local anaesthetic was prescribed,” he continued.
“The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams.
“This is of particular concern when the intention is for the drug to be diluted.
“If the drug is always prescribed in milligrams then the scope for error may be reduced.”
He said that the “hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation”.
“However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure,” said the coroner.
“And that it is common to use similar practice to that which occurred during this operation.”
The Royal College of Anaesthetists has a duty to respond to the coroner within 56 days of the date of his report, by October 29.
Dr Gibson, a cancer scientist, had a first class degree in anatomy and human biology from King’s College London and completed her PhD in neuroendocrinology at Downing College, Cambridge.
Her widower, Cliff Gibson, described her as a “wonderful mum” and an “amazing wife”.
The 49-year-old said: “In her profession, Rachel cared about the process and doing everything right for her patients at all times.
“She loved her career, the industry she worked in and trusted in the medical system and those in it more than anyone.
“She went into her operation with the clear belief that it would be a success and she would be able to regain her mobility and enjoy living her life again.
“It was devastating for us as a family to learn that there is a fundamental problem with inconsistencies and ambiguities in the way anaesthetics are given to patients across the country.”
He continued: “Major changes need to be made and we will do everything we can to ensure that happens so that appalling mistakes like this never happen again.”
Published: by Radio NewsHub