Review of clinical incidents
Following is a review of incidents reported to the NHS in England and Wales in the period from 1 October 2023 – 31 March 2024.
Stroke following anaesthesia – possible air entrainment by faulty fluid warmer
[Patient in their 30s] had a hernia repaired under combined GA and spinal anaesthesia. Once the procedure had finished and the patient woken up, they complained of being unable to move their legs. This was initially...
Pre-operative assessment
During the pre-operative assessment before elective surgery of a patient with multiple medical comorbidities, no physical examination was undertaken. Despite an ejection systolic murmur being documented several times in the notes, an ECHO had never been requested.
Perioperative care of patients with dementia
An elderly patient with complex co-morbidities was admitted from a care home with probable large bowel obstruction. The patient appeared delirious on the ward and could not tolerate NG tube insertion.
Deterioration whilst awaiting theatre
Three days after an oesophagectomy, a patient in their 70s started complaining of abdominal pain. After 5 days of conservative treatment a CT revealed extra luminal contrast leak at the pyloroplasty site, free fluid in the abdomen, pleural effusion, atelectasis, small pneumothorax and a splenic infact.
Transfer
CASE 1
A patient who had recently undergone a laparoscopic procedure to the oesophagus at a tertiary centre was transferred back to their local hospital for post-operative care.
Familiarity with equipment (out of hours)
A Patient was admitted for emergency cardiac catheterisation in a state of cardiogenic shock with ongoing chest pain and pulmonary oedema . The anaesthetic team were called urgently. An anaesthetist, who was unfamiliar with the equipment, arrived without an ODP, but could not activate capnography.
Tracheal injury
A patient suffered tracheal injury secondary to difficult placement of a double lumen tube. Bronchoscopy revealed defectin the left bronchus + injury to the distal trachea.
Following MDT - patient put on VV ECMO, and the injury repaired. The patient is recovering on intensive care unit, still awaiting surgery for lung cancer.