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Don't blame it on the bougie

01 May 2008

Mr J, a 40-year-old taxi driver, was scheduled to undergo bariatric surgery for morbid obesity. He was a motivated individual and a good candidate for surgery. Mr S, the consultant surgeon was experienced with the procedure. The usual anaesthetist for this regular list was unavailable, and so Dr B provided the service. Dr B, although an experienced consultant anaesthetist, was not familiar with anaesthesia for bariatric surgery. Dr B visited Mr J pre-operatively, but did not make more than a brief note about the visit. There was no record of discussion about the particular risks of anaesthesia for bariatric surgery.

The surgical procedure required that the anaesthetist pass a bougie down the oesophagus into the stomach. The anaesthetic chart made no mention of difficulties with either intubation or the bougie. The patient became unwell after the operation and eventually a diagnosis of mediastinitis secondary to unrecognised traumatic oesophageal perforation was made.

The patient was admitted to intensive care for three weeks, and required extensive support for multiorgan failure, and further surgery. He was left with impaired respiratory function. 
He brought a claim against both the anaesthetist and the surgeon.

Expert opinion

Careful scrutiny of the notes and anaesthetic record by experts revealed poor documentation of the peri-operative events. In addition, Dr B mentioned that he had had some difficulty passing the bougie, yet there was no mention of this in the notes, which may have led to earlier diagnosis and treatment of Mr J’s injuries. There was no mention of any of the anaesthetic risks associated with this particular type of surgery. Expert opinion was divided as to whether it would have been appropriate to warn patients about the rare risk of oesophageal perforation.

It was clear that the poor documentation of events, and the lack of documented discussion between the surgeon and the patient, made it impossible to defend the claim. It was settled for a substantial sum.

Learning points

  • It is prudent to discuss the risks of anaesthesia with the patient. How much detail is required is a matter of professional judgment; however, GMC guidance is clear that there ought to be disclosure of material or significant risks even though they may be rare (GMC, Consent: Patients and Doctors Making Decisions Together (2008) paras 28-32). The presumption has to be that a patient would want to know of the catastrophic risks and, unless they expressly state that they do not want to be told of them, the clinician should inform them as per the guidance.
  • The importance of careful documentation of events, including the anaesthetic record, cannot be overemphasised. Although not in themselves a complete defence against a claim of negligence, they do provide documentary evidence that may make it easier to defend a claim. Conversely the absence of documentation makes it very difficult to defend a claim. It also creates a poor impression of professional competence.
  • The GMC is clear that doctors should not act beyond their professional competence. Thus, when faced with a new procedure, the individual should seek suitable training and/or supervision before attempting such procedures.

References

  • Consent for Anaesthesia – Revised edition for 2006, The Association of Anaesthetists of Great Britain & Ireland (2006)
  • Peri-operative Management of the Morbidly Obese Patient, Association of Anaesthetists of Great Britain & Ireland (2007)
  • Adams A M and Smith A F, Risk Perception and Communication: Recent Developments and Implications for Anaesthesia, Anaesthesia, 56;745–55 (2001).