Death On Table

Question 1

Step 1

Answer 1

Breath pray, sit down…take a moment to regain your composure

Question 2

Step 2

Answer 2

Records
- If possible, designate one person during the resuscitation to keep a record of
the sequence of events, including personnel involved, times, drugs and fluids
used, interventions and procedures performed, and the outcomes
- After the event, make accurate, detailed notes on the anaesthetic chart of
the anaesthetic given and the events as they occurred
- No alterations should be made to the original notes, if any additions or
amendments need to be made, these should be recorded separately, signed,
timed and dated
- Ideally, details of the preoperative discussion with the patient should have
been documented – including risks of the anaesthesia and consent for
regional techniques.
- Make a photocopy of the anaesthetic chart, copies of relevant investigations
for your personal record, as well as a personal set of notes detailing the event
“Your personal notes should include every detail of the routine followed for
this patient – when the patient was first seen, by whom, what was
prescribed, investigations and results, anaesthetic plan - everything you
know now, but when asked in 2 years time in the context of a civil case, you
will not be able to remember at all! Most of our routines are so automatic
that we forget we even did them” 3 or we consider it assumed knowledge.
From a medico-legal point of view: make no assumptions, and the more
detail the better.

Question 3

Step 3

Answer 3

Supporting the Anaesthetist
In the period immediately following the death, aspects that our anaesthetic
colleague may need assistance with are:
- Inform the senior registrar / consultant on duty
- Quickly review the case and go over the sequence of events that transpired
while still fresh in one‟s memory
- Help to complete documents and make appropriate patient notes
- Help from a senior to speak to the patient‟s family
- Depending on the circumstances a decision will need to be made together
with the anaesthetist involved and the senior whether or not they are fit to
complete their slate/call or whether they need to be relieved of their duties

Answer 4

Dealing with the patient
- Any death occurring whilst under the influence of anaesthesia constitutes a
procedure-related death6, and will necessitate further investigation and post-
mortem
- All lines, tubes, drains and other equipment connected to the patient must
be left in place, and a detailed description should be made thereof. If any
doubt exists regarding the position of the endotracheal tube, this should be
checked and recorded by a second anaesthetist.
- Documentation should be completed as soon as possible to expedite the
process and to facilitate transfer of the body to the mortuary

Answer 5

Communicating with the relatives
- Whenever possible, such news should be communicated to the family in
person. You may need to contact the family telephonically, inform them that
a serious complication has occurred and ask them to come to the hospital to
speak in person. Try to avoid disclosing the news of the death over the
telephone.
- Find a quiet, comfortable room to sit down with the family. The initial
meeting will involve informing them what has occurred, and answering any
of their immediate questions.
- Never speak to the family alone, ideally you and the surgical colleague
involved should speak to them together, including a member of the nursing
team and an interpreter if necessary.
- Before the meeting, you and the surgeon should decide jointly on what
information to disclose. Offering conflicting versions of events creates mistrust and such miscommunication could be the root of possible litigation.
- If the cause of death is known, then this should be explained in simple
terms. If no cause has been determined yet, do not speculate or offer an
opinion – rather inform them that the matter is under investigation.
- Be empathetic. Offering an apology does not imply fault.
- The family will likely need time to process the news, don‟t give too much
detailed information initially, but rather schedule a second meeting, if
necessary, to answer further questions.
- Inform them of the procedure that will follow regarding a post-mortem and
whom they can liaise with to enquire when the body will be released for
funeral arrangements

Question 6

Step 6

Answer 6

Documentation to Complete
- A perioperative death in theatre mandates the completion of a GW24/7 form.
- For an unnatural death in the Intensive Care Unit (KEH and IALCH), we
complete an “Unnatural death form” and standard discharge summary.
- These forms go through to the Forensic Pathologist. The purpose of these
forms is to provide as much detail as possible to assist the Forensic
Pathologist and inquest Magistrate in understanding the events that
transpired and in making their findings. Upon completion of their
investigation, the Forensic Pathologist will issue a Notification of Death form
(DHA-1663).

Question 7

Subsequent Actions

Answer 7

1. Equipment and drugs
   - If there is any suspicion of malfunctioning equipment in the theatre or drug
   irregularities, this may warrant further investigation. A decision will need to
   be made in conjunction with theatre matron whether to take the theatre or
   individual equipment out of commission until such time that its safety can be
   verified by medical equipment maintenance personnel, manufacturers or
   toxicologists.
2. Debriefing the theatre team
   - Ideally all members of the theatre team (including nursing and technical
   staff) involved in the case should be debriefed as soon as is possible or
   convenient after the event. Having a short, even informal discussion
   together of the events that transpired, in an open honest manner could go a
   long way in gaining information, feedback, relieving anxiety, blame; and in
   maintaining the camaraderie of the theatre teams we work with each day.
3. Communicating with the media
   - Following the intraoperative death of patient, there may be scenarios in
   which the media may be involved and approach the hospital staff for
   statements. A nominated hospital representative should be the only person
   liaising with the media and all enquiries should be directed to this person.

Question 8

.

Answer 8

1. Equipment and drugs
   - If there is any suspicion of malfunctioning equipment in the theatre or drug
   irregularities, this may warrant further investigation. A decision will need to
   be made in conjunction with theatre matron whether to take the theatre or
   individual equipment out of commission until such time that its safety can be
   verified by medical equipment maintenance personnel, manufacturers or
   toxicologists.
2. Debriefing the theatre team
   - Ideally all members of the theatre team (including nursing and technical
   staff) involved in the case should be debriefed as soon as is possible or
   convenient after the event. Having a short, even informal discussion
   together of the events that transpired, in an open honest manner could go a
   long way in gaining information, feedback, relieving anxiety, blame; and in
   maintaining the camaraderie of the theatre teams we work with each day.
3. Communicating with the media
   - Following the intraoperative death of patient, there may be scenarios in
   which the media may be involved and approach the hospital staff for
   statements. A nominated hospital representative should be the only person
   liaising with the media and all enquiries should be directed to this person

Answer 9

• Departments should be prepared to exercise flexibility and a commitment to
  providing support to the anaesthetist who may be stressed or emotionally
  traumatized after the event. Aside from the personal wellbeing of the
  anaesthetists themselves, the guidelines highlight that a “stressed anaesthetist
  will be more prone to making errors”4
  , which helps neither the department nor
  the subsequent patients who come under their care.
• In the immediate time period following the event, it may be necessary to
  arrange for someone to take over the anaesthetist‟s duties or complete his/her
  call should s/he feel unable to do so.
• An informal debriefing following the event is strongly suggested, where
  necessary a trusted senior colleague should be assigned to mentor and
  provide support to the anaesthetist for as long as they may need it. This could
  involve follow-ups with the anaesthetist (formal or informal) in the weeks
  following the event.
• At a later stage, review of the case in a departmental Morbidity and Mortality
  meeting may be a useful learning tool.
• Provide retraining, if needed, in a particular skill that the anaesthetist had
  difficulty with during the case - eg: management of a difficult airway.

Question 10

MEDICO-LEGAL ISSUES RELEVANT TO THE ANAESTHETIST

Answer 10

South African law stipulates that any death considered unnatural must be
reported for medico-legal investigation.

Question 11

Unnatural Death

Answer 11

Apart from Anaesthetic-associated deaths as specified in Section 56 of the Health
Professions Act of 19748, there is currently no complete legal definition of an
unnatural death. Dada and McQuoid-Mason9state that it is generally accepted for
a death to be categorized as unnatural if it is caused by:
(a) the application of force, direct or indirect, and its complications (eg: a stab or
bullet wound, road accident); or
(b) physical factors (eg: heat, cold, radiation) or chemical effects (toxic
substances, drugs, venomous snake bites); or
(c) where another person by negligent act or omission can be held responsible
for it; or (d) any death which is sudden and unexpected, or unexplained.

Question 12

Inquests Act 58 of 1959

Answer 12

According to the Inquests Act 58 of 1959, all unnatural deaths are subject to a
formal inquest whereby a magistrate is required to ascertain (a) the identity of the
deceased; (b) the likely cause of death; (c) the date of death; and (d) whether the
death was brought about by any act or omission involving or amounting to an
offence on the part of any person. 10
An inquest is not a trial and no persons stand accused of a criminal or other
unlawful act. However should the inquest find that a doctor was responsible for a
person‟s death by an act or omission that amounts to an offence, the magistrate
may refer the inquest finding to the Director of Public Prosecutions for possible
criminal action against the doctor 9 in terms of the Criminal Procedure Act 51 of
1977
Dada and McQuoid-Mason also emphasize that the responsibility of the
anaesthetist extends beyond just the anaesthetic in theatre, but includes the care
and monitoring of patients in the recovery room as well. Should a patient die
during the recovery stage post-operatively as a result of negligence by the doctor,
he/she could face charges of culpable homicide.

Question 13

Health Professions Act 56 of 1974 (Section 56)

Answer 13

Death associated with anaesthesia was previously defined in Section 56 of the
Health Professions Act56 of 1974 whereby “The death of a person whilst under
the influence of a general anaesthetic or local anaesthetic, or of which the
administration of an anaesthetic has been a contributory cause, shall not be
deemed to be a death from natural causes”.
8 Under the provisions of this act, all
Anaesthetic-associated deaths necessitated a post-mortem and formal inquest.

Question 14

Health Professions Amendment Act 29 of 2007 (Section 48)
An important point to note, is that there is no consideration of the time frame
between the Anaesthetic/procedure and the death. Many clinicians previously
used a so-called “24-hour” rule - a misconception that if a death occurred within
24hours of the Anaesthetic, it should be reported as unnatural

Answer 14

In 2007, the HPCSA introduced a revised version of this act: the Health
Professions Amendment Act 29 of 2007 which states that “The death of a
person undergoing or as a result of a procedure of a therapeutic, diagnostic or
palliative nature, or of which any aspect of such a procedure has been a
contributory cause, shall not be deemed to be a death from natural causes”.6
Madiba et al note that “while the original clause in section 56 of the Health
Professions Act made deaths related to anaesthesia reportable, there was no
specific provision for the reporting of deaths related to a procedure.” 7The
Amended legislation now addresses this.

Answer 15

Whereas if the death occurred more than 24 hours after anaesthesia, many
clinicians felt it could be reported as natural provided that the patient recovered
fully from the anaesthetic. According to the legislation, no such time frames exist.
If it can be shown that a causal link exists between the anaesthetic/procedure and
the death, regardless of the amount of time that passes between the two (a week,
a month, a year) the two are regarded as being related, and is therefore deemed
unnatural.11

Answer 16

While the new legislation does extend the scope of deaths that are statutorily
defined as non-natural, the key point to remember is that the practitioner still
retains the discretionary power to decide if it is likely that a causal association
exists between the anaesthetic/procedure and the death (i.e.: if the
anaesthetic/procedure resulted directly in the patient‟s death or if it played a
contributory role to the death.) If this is so, then they refer it to Forensic Pathology
as a procedure-related death

Answer 17

1) A patient who dies on table during anaesthesia (the cause of death i.e.:
whether it is related to the pathology itself, to the surgery or the anaesthesia,
is left to be determined by the investigation)
2) A patient who hasn‟t fully recovered from effects of general anaesthesia,
develops upper airway obstruction in recovery room, has a hypoxic arrest
and dies.
3) A patient who aspirates on table, develops a pneumonia and dies two week
later from subsequent complications
4) A patient who has a stroke post CEA and dies in ICU two weeks post-op
5) A patient for elective cholecystectomy who develops wound sepsis,
subsequent DVT and dies from a pulmonary embolism three weeks after
the initial surger

Answer 18

Another important point to note however, is that classifying a death as unnatural in
a case where an anaesthetic was administered or a specific procedure
undertaken, does not imply negligence/fault/or wrong doing on the part of the
practitioners (anaesthetists/surgeons) managing that patient. If it can be shown that the basic standard of care was applied to the patient, and
that reasonable steps were taken to prevent anticipated complications, the
practitioners have no reason to fear the outcome of post-mortem. Practitioners
should not falsely classify a death as natural simply to avoid medico-legal
investigation.

Answer 19

The advice offered by most legal and forensic specialists is that if there is any
doubt as to how to categorize a specific death – then the best recourse would be
to discuss the case with the local Forensic Pathologist, and once a joint
decision has been reached, to clearly document all the steps taken.

Question 20

Birth and Deaths Registration Act 51 of 1992

Answer 20

This act defines the conditions under which a doctor may or may not issue a
death certificate. “Where a medical practitioner is satisfied that the death of any
person who was attended before his/her death by the medical practitioner, was
due to natural causes, he/she shall issue a prescribed certificate stating the cause
of death. A medical practitioner who did not attend the person before his/her
death, but examined the corpse after death and was satisfied that it was due to
natural causes, may issue a prescribed certificate to that effect. If the medical
practitioner is of the opinion that the death was due to other than natural causes,
he shall not issue a certificate but must inform a police officer to his/her opinion in
this regard

Answer 21

n practice, however, the doctor would either complete a „Notification of Death‟
form DHA-1663 and tick the box marked „unable to certify that the deceased
died solely due to natural causes’, or would complete an Unnatural Death form.
The case would then be treated as unnatural and referred to Forensic Pathology
for post-mortem and further investigation to determine the cause of death. The
Forensic Pathologist would then issue the Notification of Death form DHA-1663.

Answer 22

The original Notification of Death form, BI-1663 has now been replaced by form
DHA-1663. The content of the new form is essentially the same, but now
comprises a 3-page part A and a one-page part B.

Answer 23

“The Primary Medical Cause of Death is the first disease or injury that set in and
which ultimately led to the death of the individual (whether directly or by way of
late complications). Examples would be a stab wound to the neck (non-natural
cause) or atherosclerotic coronary vessel disease (natural cause).

Answer 24

Mechanism of Death is the pre-terminal pathophysiological disturbance or
complication which actually terminated the life of the individual. Examples would
be hypovolaemic shock or sepsis following a stab wound to the neck, or
myocardial rupture with tamponade, secondary to myocardial infarction.”1

Answer 25

detailed medical examination of a dead body to determine the cause of death or to
study the character and extent of changes produced by the disease.9 An autopsy
may be carried out under 3 circumstances:
1) Autopsy is mandatory for all unnatural deaths according to the Inquests Act
58 of 195910
– consent from family is not required.
2) An autopsy may be requested by the doctor for academic purposes where
death is categorized as natural but the cause is uncertain. This would be
done by the anatomical pathologists, not the state forensic pathologists -
consent from family is required.
3) Autopsy may be requested by the deceased‟s family even if categorized as a
natural death by the doctor. The autopsy may either be conducted by a
private pathologist enlisted by the family, or the family may open a case with
the South African Police Services and have the autopsy done by the state
pathologist. If the family wishes to do so, a private pathologist enlisted by
them may be present at this autopsy.

Question 26

Anaesthetic death definition b

Answer 26

Anaesthetic-associated Deaths i.e. all deaths that occur while the patient is under the influence of
a local or general anaesthesia, or regional/spinal anaesthesia. This would include death at any
stage following the anaesthetic procedure where any aspect of the procedure undergone by the
patient has been a contributory cause. Note that there is no time limit of 24 hours stipulated by
law.

Answer 27

No DHA-1663 form should be issued. Instead the referral form FPS100 titled
“Confidential : Report on Suspected Unnatural Death” should be completed.

Answer 28

In the case of an “anaesthetic-associated” death, the GW 7/24 form must be completed in
addition to the FPS100 form.

Answer 29

An AIRMS (Adverse Incident Reporting and Risk Management) form must be completed
for any death occurring in the hospital which is :
 a suicide which occurred while the deceased was a patient in the hospital;
 anaesthetic-associated;
 unexpected.

Answer 30