A coroner had warned a common way of administering anaesthesia could lead to potentially fatal doses, following the tragic death of a women in surgery.
Dr Rachel Gibson, 47, suffered a cardiac arrest following routine hip replacement surgery at Spire Lea Hospital in Cambridge in April 2022.
While she was resuscitated, Dr Gibson was found to have suffered irreversible brain damage due to a lack of oxygen. She died three months later.
A subsequent investigation linked her death to a hospital error that led to an excessive amount of local anaesthesia being used in the operation.
Now, in a report sent to the Royal College of Anaesthetists (RCOA), coroner Philip Barlow, has warned the process that produced the error is ‘common nationally’ and ‘there is a risk that future deaths could occur unless action is taken’.
Dr Rachel Gibson, 47, suffered a 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’, ‘wonderful mum’ and ‘an amazing wife and a loyal friend to so many people’
According to the report, it was routine practice with this type of procedure for the anaesthetist to instruct the nurse as to the type and dose of anaesthetic to be used.
This dose is then prepared by the nurse who hands it to the surgeon.
But the report found the responsibility for checking and administering was ‘unclear’.
It highlighted that the anaesthetist’s instruction was given orally, not written down, and the anaesthetist didn’t check what the nurse had noted.
Mr Barlow wrote that the nurse’s notes were then handed directly to the surgeon.
There was also an inconsistency in the way the anaesthetic was prescribed by the anaesthetist with both millilitres and milligrams used somewhat interchangeably, a practice that opened the door to potential errors.
Mr Barlow wrote: ‘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.’
An inquest into the death of Dr Gibson, a medical researcher, found the intention was for a two per cent solution of Ropivacaine to be diluted with normal saline before being used.
However, evidence suggested this wasn’t done and an excessive amount of the drug was mistakenly administered.
While the report centred around Dr Gibson’s death, Mr Barlow said there were potential lessons beyond those for the hospital involved.
‘The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation,’ he wrote.
‘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; and that it is common to use similar practice to that which occurred during this operation.’
Addressing the RCOA he added: ‘This is why I believe I am under a duty to draw it to your attention’.
A spokesperson from Spire Healthcare told the BBC it offered its ‘very sincere 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 issue with the appropriate body to consider if further action should be taken and we support this important step.’
Dr Fiona Donald, RCOA president also sent their condolences to Dr Gibson’s family and that they were considering the coroner’s report.
‘We have received the coroner’s report and will examine this case in detail before responding by the 29 October,’ she said.
‘The RCoA is responsible for safeguarding standards in anaesthesia and we will do all we can to address the issues raised by the coroner to help prevent similar tragedies in future.’
Dr Gibson, worked in medical research for cancer as an expert in the interaction of the nervous system and hormones, and was a mother of one.
Cliff Gibson, 49, husband of Rachel, said: ‘Rachel was a loving daughter, a wonderful mum to Sam, an amazing wife and a loyal friend to so many people.
‘Her passion, drive and ambition was, and will always be, an inspiration.
‘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.
‘Rachel dedicated so much of her time to our autistic son, Sam, now aged 13, who still to this day struggles to talk about his mum and does not understand how she went in for what he was told was a simple operation and never came home.’
On the coroner’s report he added: ‘We have to trust that the RCOA, the body responsible for safeguarding standards in anaesthesia, will prioritise an investigation to ensure that a new and consistent national framework is adopted to avoid anyone else going through what we have experienced as a family.
‘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.’
Deaths caused by anaesthesia in the UK are very rare. The RCOA says the fatality rate from anaesthesia is about one death per 100,000 uses.
While she was resuscitated, Dr Gibson was found to have suffered irreversible brain damage due to a lack of oxygen. She died three months later. Pictured: Spire Lea Hospital in Cambridge
While the report centred around Dr Gibson’s death, the coroner said there were potential lessons beyond those for the hospital involved
However, it added that individual risk can vary significantly due to a patient’s specific health conditions and general fitness.
Deaths from inappropriate levels of anaesthesia use have been reported before.
In 2020 Manchester Crown Court heard of the death of Christopher Hales, 56, who died in hospital after the ‘catastrophic’ anaesthetic error by medic Shahid Khan, before a routine procedure.
Mr Hales, a devoted family man, had developed smoking-related lung problems.
In May 2017, he was admitted to Wythenshawe Hospital in Manchester with a collapsed left lung.
He opted for ‘talc pleurodesis’, a procedure where talcum powder is introduced into the chest cavity to ‘stick the lung to the chest wall’ and to seal holes in the lung.
But the prosecution said Khan’s preparation for, and execution, of the anaesthetic plan was ‘disastrous’.
Khan had decided to give two drugs both at their maximum dose and lost control of the amounts he was administering.
Mr Hales went into cardiac arrest with attempts to resuscitate him unsuccessful.
Khan was given a 20-month jail sentence, suspended for two years after pleading guilty to gross negligence manslaughter.
Analysis of NHS data by experts from Universities of Manchester and York have suggested medication errors, of all drug types, lead to approximately 1,700 patient deaths in England alone.
Publishing their findings in the BMJ they found the majority of these deaths, some 1,000, occur in hospital settings, with the remainder taking case in primary care, for example GPs and pharmacies.