Medico-legal Aspects of Anaesthetic Practice

10 November 2011Dr Udvitha NandasomaMedico-Legal Adviser

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Who decides a doctor’s accountability after a clinical

incident?

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58%

3%

9%

5%

11%

2%4%

8%

Claims notifications over 10 yearsDental damage

Oral/airway damage

Awareness

Drug reaction

Death/Brain damage

Aspiration

Pressure/positioning

Needle misplacement

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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 – ophthalmology1 in 8 yrs – orthopaedics

Not all settled as majority notified to MDU are successfully defended or discontinued by claimant

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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

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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 6ICU/ HDU 3Recognized complication 22Attitude 4Awareness/ Inadequacy 5Assault 1Other 8Preassessment 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

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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

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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

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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

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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

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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

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

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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

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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

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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

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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]

Any Questions?

MDU Services Limited (MDUSL) is authorised and regulated by the Financial Services Authority in respect of insurance mediation activities only. MDUSL is an agent for The Medical Defence Union Limited (the MDU).The MDU is not an insurance company. The benefits of membership of the MDU are all discretionary and are subject to the Memorandum and Articles of Association. MDU Services Limited is registered in England 3957086. Registered Office: 230 Blackfriars Road London SE1 8PJ . Copyright MDU Services Limited 2011.