For reasons of confidentiality, some facts have been changed in this case.
40yr patient presented with a 2-week history of intermittent right loin pain with associated haematuria. Investigation revealed a 2.5cm right renal stone. Patient advised to undergo percutaneous nephrolithotomy. Patient went home to consider advice.
Patient re-presents with acute attack and requests PCNL. Patient otherwise fit. All appropriate blood tests taken preoperatively and the anaesthetist informed. Patient taken to theatre and general anaesthetic commenced. Nobody at that point had reviewed the preoperative blood tests results as they were not yet available. Urologist inserts ureteric catheter into left kidney via cystoscope. Patient becomes haemodynamically unstable. Cardiac arrest. Patient successfully resuscitated initially but remained unstable. Transferred to ITU.
Patient dies. The postmortem was inconclusive. Cause of death classified as cardiac failure. It is alleged that neither doctor ensured the patient was sufficiently prepared preoperatively before the procedure went ahead.
The preoperative blood results showed low haemoglobin of 7.4 and abnormal liver function tests, the causes of which were both unknown. The exact causation of the patient’s demise is unclear. Cardiac instability may have occurred due to some underlying pathology, which had not been diagnosed preoperatively in combination with the anaesthesia.
In view of the grossly abnormal blood tests, which had not been reviewed prior to surgery, a settlement was reached.
If you organise tests on a patient, ensure you have adequate clinical systems in place to review them.