Decision report 201201313

Summary

Miss C complained that when she had a nerve block (an anaesthetic injected directly into the nerves before surgery to numb the area) some of the anaesthetic went into her artery and caused her heart to stop. She had to be resuscitated and was transferred to the intensive treatment unit (ITU) for observation for 24 hours. Miss C also complained that she was prematurely discharged from the ITU.

Our investigation, which included taking independent advice from two of our medical advisers, found that the care and treatment provided to Miss C had been reasonable. Our anaesthetist adviser (anaesthetic specialist) reviewed the clinical records and was satisfied that there had been no error with the administration of the injection. Nerve blocks should be administered under guidance from ultrasound scanning (a special scanning technique using sound waves to produce internal images of the body). It should also be administered at a specific speed. The anaesthetist adviser was satisfied that both of these were carried out correctly and that Miss C had suffered a known, but rare, complication of this type of anaesthesia. The adviser also said that Miss C's collapse was picked up right away and correct action was immediately taken to revive her. The adviser also considered it reasonable that Miss C was sent to the ITU to be observed for 24 hours following her collapse.

On the matter of Miss C's discharge from hospital the following day, both medical advisers considered that she had been appropriately assessed on admission to ITU and prior to discharge. Although Miss C's next of kin had initially been told that she would likely be transferred to a general ward before discharge home, the advisers both considered that it was reasonable that she was discharged directly home. Miss C had been assessed on the morning after the incident as being alert, mobile about the ward, eating and drinking and had passed urine following the removal of her catheter. On the decision to send her home in a taxi, the nursing adviser said that a routine ambulance can take up to 24 hours to arrange so it was reasonable to avoid this delay by sending Miss C home in a taxi.