Accidentally given a general anaesthetic instead of a spinal block at 20wks pg, should we be more concerned?

[Jamiki]

Okay, so my DSister has an incompetent cervix and is 20weeks pregnant with her second child.

Yesterday she went into hospital to have a pre arranged cervical stitch put in. Prior to the procedure she had been seen by the surgeon, the head anaesthetist and had signed a consent form (for a spinal block)and seen the admissions clerk. Seen all these people to discuss the procedure - cervical stitch to be placed under a spinal block.

She had the exact same procedure about 15months ago with first baby, relatively straight forward.

So she is in the theatre ready for the procedure and the anaesthetist comes up to her and says ' I'm going to give you something now to relax you', and proceeds to inject something into her hand, DSister wasn't too alarmed as she had been given a premed last time but she did say 'why, I'm supposed to be having a spinal block' at which point she was now 'under'.

Upon waking from the GA in a fuzzy state she's saying to herself 'God, I hate waking up from a GA, OMG, hang on, I wasn't supposed to be waking up, I was supposed to BE awake the whole time with a SPINAL BLOCK!'

The anaesthetist was at her bedside and straightaway says' Look, that shouldn't have happened, there was a communication breakdown. (?) I've checked all the drugs you have been given and none will harm your baby'.

DSister requested and had a midwife come down and check the baby and all seemed well.

The error was not recorded on the anaesthetic record, only that she'd had a GA.
DSister had to request more than once that an incident report be filed.
DSister had a phone conference with the anaesthestist today where basically she (DS) said she was happy enough with how it was handled but wanted it well documented in case there was a problem or something with the baby resulting from the 'mix up'.

She is happy enough to go ahead with the planned caesarian in November at the same hospital (which is not a big teaching or womens hospital).

We are both in that this has happened but she is a lot calmer than I imagine I would be. We are both trained nurses (not midwives) and so is our Mum.

I/we would be having this conversation with our Mum but her and my Dad took off on holiday two days ago and have been out of range though she will be in touch soon. So we are missing her guidance right now.

I personally cant get over these things right now.

• There was no signed consent form for a GA.

• She was 20wks (and obviously) pregnant getting a stitch, is that usually done under GA?

• There was two anaesthetists and an anaesthetists assistant in the room and apparently not one of them read the notes enough to provide the correct anaesthetic???

• Surely there is a HUGE difference between a spinal block and a GA and this is not a easy mistake to make?

DSister doesn't feel inclined to 'take any further action', nor do I want to pressure her but I'm posting this with her consent just to see 'if we should be more concerned' at all or if it should just be 'let go' and get on with things?

What do you think?

Sorry it's long .

[ladyjadey]

Wow! as a pregnant nurse I am shocked as hell that a mistake of this magnitude was allowed to occur!

I can't really offer any advice of value, except to say that you were right in insisting in an incident report being filed. If I were you, I would insist on copies of all the notes just in case, as these things DO go missing, particularly in a complaint situation, terrible as that is.

People do safely have GA in pregnancy from time to time, my sis actually had a thyroidectomy while pg with her 1st, and it's generally problem free, however we are so concerned about what we put into our bodies when pg, taking paracetamol is a big deal!

Just cover yourselves, have evidence in case of future problems, seek legal advice and speak to PALS if you have any other concerns. I'm sure all will be ok tho, the biggest risks with a GA are whilst the procedure is happening, chances are if she has recovered well all will be fine.

[bibbitybobbityhat]

As reassurance to your sister, its worth remembering that quite a lot of babies are actually delivered while the mother is under general anaesthetic (including mine). And I assume it is a very quick procedure - how long was she under for?

But wow!

I imagine your sister is not keen to increase her stress levels any further, but in her shoes I most certainly would complain at the very highest level because that whole story shows astonishing incompetence.

[squistle]

I would be down the solicitor's office straight away seeing what I could do! If anything happened to my unborn baby I would never be able to forgive my self for not doing anything.
If it has happened once it might happen again to someone else and I wouldn't be able to forgive myself for not speaking up in that situation either.

[Jacksmybaby]

Sorry I have no helpful advice but just wanted to say...

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

[LittleSilver]

Have you requested:

• Copy of incident form
• Notes
• Anaesthetic chart

Personally I'd be inclined NOT to have phone conversatiosnw ith ANYONE, rather e-mails/letters thatcan be copied. I'd also be requesting GMC numbers.

I have NO idea how that could happen. Do they not do "Time Out" at the start of the surgery at your hospital (I guess not)

[LittleSilver]

Sorry, have no idea as to whether you should be concerned/not concerned as am not anaesthetist. But am shocked that this happened.

[Jamiki]

Thanks ladies, getting copies of notes in case they disappear is a great idea and will follow that up.

We are in Australia so not sure what PALS is but no doubt we have something similar, what does it stand for out of curiosity?

[LittleSilver]

Patient Advice and Liaison Service.

[Jamiki]

LittleSilver - Thanks.

[Funloving]

Crikey, that's terrible. But, people can and do have ops perfectly safely under GA, and they checked the drugs were ok, so I'm sure no harm done. Re complaining - you can do, and it is worth it just to flag up issues with systems - however from a compensation/solicitors point of view, unless there is a harmful event that came out of a mistake (which at the moment there isn't any evidence of), there's no point (that's the case in the UK anyway). But always worth putting things in writing so it can be looked at and put right for the future.

[Alicetheinvisible]

That is shocking!

FWIW i had a GA at 20 weeks after a severe break to my leg and DD was fine. They kept a monitor on her the whole time apparently. The morphine and blood loss was more of a concern tbh.

[EggsandBacon]

I'm just really shocked for your sister!! The other suggestions about keeping a record of everything that has happened seems really good to me, just in case any problems.

But as reassurance on the GA side, my Mum had a GA when a bit more than 20 weeks pregnant with me, and I've never had a health problem. I know it's just anecdotal, but I hope that lends further weight to the idea that your sister's baby won't have been harmed at all.

Really shocked at the mix up though.

[oldmum42]

My concern would not be about the effects of the GA, but the system failure that led to this happening - was it a case of them not reading the notes regarding the spinal(bad), or did they actually mix up two patients, potentially much more dangerous.

No wonder the doc was sitting by the bed waiting for your sis to wake. The whole team must have been shiting themselves - this is not the mistake of 1, person, but of a system, checks not done properly etc.

[Jamiki]

It's such a relief to hear that GA while pregnant is not huge deal. Thanks.

LittleSilver - what are GMC numbers?

[MadameCheese]

Bloody hell!!!!!! I'm sorry but she must complain, this is slightly more than a breakdown in communication. Hope she is ok and pregnancy goes well.

[Jamiki]

Oldmum42- I agree, as a trained HCW I know how many checks and balances are (usually) in place for any type of medical intervention.

As a pregnant woman (also) I can only imagine how my sister felt waking up alone in theatre after such a monumental screw up where control was totally out of her hands. I mean you're helpless enough as it is when you are a patient without being rendered unconscious by mistake.

[Jamiki]

Bibbity - sorry, not sure how long she was under for. Will get back with an answer.

[going]

That is a shocking mistake even though her and her baby were not harmed.

I've had three stiches and had them with a spinal but could have opted for a GA. She porbably was under for long - procedure only takes about 10 mins. Hope the rest of her pregnancy is uneventful!

[going]

probably wasn't under for long I meant to say!

[cluelessnchaos]

That is awful, I had a stitch with dd1 and was done under GA, obviously to no ill effect, it sounds like your sis is dealing with this really well

[cardamomginger]

Also completely shocked by what happened. GMC stands for the General Medical Council - all doctors in the UK have to be registered with the GMC to practice and each has their own identification number. There must be something similar in Australia.
I'd also make sure that the obstetrics consultant in charge of her care knows that this happened. If I was that obs/gynae consultant I'd be furious that such a cock up occurred with one of my patients. But quite apart from that, he/she is best placed to determine whether the GA is safe for your sister at her stage of her particular pregnancy.
Not sure of all the legal ins and outs, and quite understand that your sister just wants to get on with things rather than having to contend with taking things further, but surely if someone adminsters a drug or conducts a procedure without your consent (assuming it's not a life/death situation which this wasn't), then isn't this assault?

[Jamiki]

Thanks ladies, you've definitely put my mind (and DSis's when she sees this no doubt) at rest re safety in pg of GA.

Will follow up other suggestions.

[mosschops30]

As a nurse (anaesthetics and itu), and someone who has suffered rcently at the hands of incompetent doctors and midwives I can only advise the following:

Make sure a clinical incident form was filled in
Make sure you keep notes of everything that has happened.
Request to speak to both the consultant surgeon and the consultant aneasthetist.

TBH I cant imagine how this happened, and how the surgeon didnt discuss with the aneasthetist beforehand what was going to happen.

I'd be fucking livid if this happened to me and would certainly take things further

[Jamiki]

Thanks mosschops - kind of how I feel. I will definately encourage my sis to get copies of notes etc.