A coroner has warned that a common way of administering anaesthetic could lead to potentially fatal doses, following the tragic death of a woman in surgery.
Dr Rachel Gibson, 47, suffered cardiac arrest following routine hip replacement surgery at Spire Lea Hospital in Cambridge in April 2022.
While she was being resuscitated, Dr Gibson discovered that she had suffered irreversible brain damage due to lack of oxygen. She died three months later.
A subsequent investigation linked his death to a hospital error that resulted in the excessive use of local anesthesia in the operation.
Now, in a report to the Royal College of Anaesthetists (RCOA), coroner Philip Barlow warned that the process that led to the error is “common nationwide” and “there is a risk that deaths could occur in the future unless action is taken”.
Dr Rachel Gibson, 47, suffered cardiac arrest, meaning her heart stopped, following routine hip replacement surgery at Spire Lea Hospital in Cambridge in April 2022.
A tribute page set up in Dr Gibson’s name described her as a “loving daughter”, a “wonderful mother” and an “amazing wife and loyal friend to so many people”.
According to the report, it was standard practice for the anesthesiologist to instruct the nurse on the type and dose of anesthesia to be used in such procedures.
The nurse then prepares this dose and gives it to the surgeon.
But the report concluded that responsibility for monitoring and management was “not clear”.
He stressed that the anesthesiologist’s instruction was given orally, not in writing, and that the anesthesiologist did not verify what the nurse had noted.
Mr Barlow wrote that the nurse’s notes were then given directly to the surgeon.
There was also an inconsistency in the way the anesthesiologist prescribed the anesthesia, with both milliliters and milligrams being used almost interchangeably, a practice that opened the door to potential errors.
Mr Barlow wrote: “This is particularly worrying when the intention is to dilute the medication. If the medication is always prescribed in milligrams, the margin of error may be reduced.”
An inquest into the death of Dr Gibson, a medical researcher, found that a two per cent solution of ropivacaine was intended to be diluted with normal saline before use.
However, evidence suggests that this was not done and that too much of the drug was mistakenly administered.
While the report focused on Dr Gibson’s death, Mr Barlow said there were potential lessons beyond those of the hospital involved.
“The hospital in question has introduced a system to label and endorse the medication administered during the operation,” he wrote.
‘However, the evidence at the inquest was that nationally there is wide variation in the way local anaesthesia is prescribed, monitored and administered in this type of procedure; and that a similar practice to that which occurred during this operation is common.’
Addressing the RCOA, he added: “That is why I feel it is my duty to draw your attention to this matter.”
A spokesperson for Spire Healthcare told the BBC He offered his “deepest condolences to the family of Rachel Gibson for their loss.”
“We note that the coroner, having heard the evidence, has taken the decision to raise a national matter with the appropriate body to consider whether further action should be taken and we support this important step.”
RCOA president Dr Fiona Donald also sent her condolences to Dr Gibson’s family and said they were considering the coroner’s report.
“We have received the coroner’s report and will examine this case in detail before responding by October 29,” he said.
‘The RCoA is responsible for safeguarding standards in anaesthesia and we will do everything we can to address the issues raised by the coroner to help prevent similar tragedies in the future.’
Dr. Gibson worked in cancer research as an expert on the interaction of the nervous system and hormones, and was a mother of one child.
A tribute page set up in her name described her as a “loving daughter”, a “wonderful mother” and an “amazing wife and loyal friend to so many people”.
In the UK, deaths caused by anaesthesia are very rare. The RCOA states that the mortality rate from anaesthesia is approximately one death per 100,000 uses.
While she was being resuscitated, Dr Gibson discovered that she had suffered irreversible brain damage due to lack of oxygen. She died three months later. Pictured: Spire Lea Hospital in Cambridge
While the report focused on Dr Gibson’s death, the coroner said there were potential lessons beyond those of the hospital involved.
However, he added that individual risk can vary significantly due to a patient’s specific health conditions and overall physical condition.
Deaths have been reported previously from inappropriate use of anesthesia levels.
In 2020, Manchester Crown Court heard of the death of Christopher Hales, 56, who died in hospital after doctor Shahid Khan’s “catastrophic” anaesthetic error ahead of a routine procedure.
Mr Hales, a dedicated family man, had developed lung problems related to smoking.
In May 2017, he was admitted to Wythenshawe Hospital in Manchester with a collapsed left lung.
He opted for ‘talc pleurodesis’, a procedure in which talc is introduced into the chest cavity to ‘glue the lung to the chest wall’ and seal holes in the lung.
But prosecutors said Khan’s preparation and execution of the anaesthetic plan was “disastrous”.
Khan had decided to administer two drugs in maximum doses and lost control of the quantities he administered.
Mr Hales suffered cardiac arrest and attempts to revive him were unsuccessful.
Khan was sentenced to 20 months in prison, suspended for two years, after pleading guilty to manslaughter by gross negligence.
Analysis of NHS data by experts at the Universities of Manchester and York has suggested that medication errors, involving all types of drugs, are responsible for around 1,700 patient deaths in England alone.
Publish your findings in the British Journal of Medicine They found that most of these deaths, around 1,000, occur in hospital settings, with the remainder in primary care, for example GPs and pharmacies.