1.27 Perioperative Death Flashcards
Describe initial management of patient who dies on table
ID and contact the next of kin
Request come hospital urgently
Arrangement with nurse in charge of of patients ward
suitable room privacy and dignity
Bereavement counsellor / nurse w. bereavement experience
Inform consultant anaesthetist on call
Ensure anaes and surgical team have time to debrief
?Possible find someone to take over clinical responsibilities
- allows time to reflect
- focus on coordinating next steps for patient
- removes from work where attention may not be focused
Most hospitals have protocol
Management
Discussion by MDT
most senior member of each
Describe the events leading to fact death occurred
simple uncomplicated manner
avoid jargon
Allow time to reflect and question
Explain process of investigation and requirement for coroner r/f
Apologizing =/= guilt
Do not offer opinions / hypothesis
just facts
Consider further appts
more qs clarify issues
Management
Detailed notes of management asap after event
Retrospective continuum
times referrals therapies and copy anaes chart
Obtain printout data machine possible
signed legible dated black ink
document discussion w/ patient regarding risk and motility
death during operation
mandated coroner r/v
all lines tubes etc left in situ
specialty team informed asap
trust incident form
contact defence union
copy of own notes
Role of anaesthetic dept
Support colleague
cover shift allow time reflect
advice and counselling
Senior member act as liaison / mentor
r/v case clinical director
assess immediate risk similar events
initiates attempts to reduce risk
Dept r/v case possible learning points
co-ord by individual not involved in provision of care
Role of hospital
legal liaison officers
attempts to r/v events
try ensure no system or operational errors contributed
early
