Researchers from the Association of Anaesthetists and NHS Resolution have published a review of medical negligence claims related to anaesthesia.
Since 1995, NHS Resolution (previously known as the NHS Litigation Authority or NHSLA) has defended the NHS against medical negligence claims arising from negligent NHS care in England. All NHS Trusts in England report claims that are made against them to the Clinical Negligence Scheme for Trusts, which is run by NHS Resolution and meets the cost (compensation and legal costs) of claims through its members’ contributions.
The review analysed all of the 1230 anaesthetic negligence claims that were reported to NHS Resolution between 2008 and 2018, and compared them to a similar analysis of claims from 1995 to 2007. The review included cases relating to general, regional and managed (no drug) anaesthesia but did not include cases relating primarily to pain management or ICU care.
The review aimed to highlight trends, higher risk areas and the financial impact of claims in NHS anaesthetic practice and, by sharing learning, to reduce avoidable harm to patients and future anaesthesia-related litigation.
The review highlights that currently no formal system exists in England to analyse and learn from claims related to anaesthesia and calls for the establishment of a structure for national review and learning from all cases of litigation.
What were the results of the anaesthetic claims review?
Anaesthesia is the single largest hospital specialty. Anaesthetists care for patients during approximately 4 million procedures in the UK or 3.3 million in England each year. In two thirds of all admissions to hospital, an anaesthetist is involved in the patient’s care. Despite the high volume of anaesthetic care, claims relating to anaesthesia represent only a small amount of the overall numbers and cost of claims arising from NHS care. Anaesthetic negligence claims increased in number ( 62% higher ) and in cost (over 300% higher) annually from 2008 to 2018, compared with claims from 1995 to 2007. But those claims were only 1.5% of all claims submitted to NHS Resolution, and 0.7% of total medical negligence claims costs, in both cases lower than in the previous 12 years.
Fewer anaesthetic claims related to where the patient had died but more involved severe outcomes for the patient. Overall, the proportion of anaesthetic claims associated with severe or fatal outcomes had increased from 20% to 53%.
The highest proportion of successful claims, resulting in settlements for the injured patient, were seen in cases involving inadequate anaesthesia (82%), drug error (79%) or poor planning (78%), such as failure to recognise the higher risk status of patients with pre-existing health conditions (comorbidity).
The total costs (compensation and legal fees) were highest in anaesthesia-related claims involving cardiac arrest (£21 million), regional anaesthesia (£14.1 million), and drug error (£14.4 million). Two such claims arose from ‘wrong route’ drug errors involving intravenous (IV) administration of large volumes of local anaesthetic, both with a moderately severe outcome.
Obstetric (childbirth) anaesthesia
More than 75% (down from 89%) of all anaesthetic negligence claims related to central neuraxial blockade (including spinal and epidural anaesthesia). The drop in the number and proportion of claims related to central neuraxial blockade was also seen in claims related to obstetric (childbirth) anaesthesia.
The review highlighted that this downward trend in obstetric anaesthetic claims is encouraging, given that over 1,000 birth-related claims were submitted to NHS Resolution in 2019/2020 alone. They also highlighted that anaesthetic risk factors, such as maternal age and comorbidity have increased, obstetric anaesthesia is more often classed as emergency work and is more frequently delivered by junior doctors without direct supervision than almost any other anaesthesia sub-specialty.
A high proportion of claims related to pain or awareness during caesarean section, and failed or repeated attempts at central neuraxial blockade (spinal or epidural anaesthesia).
Anaesthetic claims involving the patient’s airway
Claims arising from negligent care of the patient’s airway, were infrequent (9%) but costly, and arose from some of the worst injuries, with 58% of patients suffering severe outcomes, including permanent neurological, respiratory and/or psychological injury. 31% of airway management anaesthetic claims involved the patient’s death.
Anaesthesia claims involving central venous catheters
A central venous catheter is sometimes known as a central line. Central venous catheters are placed into a large vein to allow IV access to administer medication to critically ill patients, or blood and fluid products needed during resuscitation, or where vascular access is needed for long term IV treatment such as antibiotics, or specialised treatment, such as haemodialysis.
Central venous catheters are sometimes associated with claims for severe injury caused, for example, by air embolism, infection, perforation, blockages and thrombosis. The review found that 2% of claims related to central venous catheters but the severity of injury (including 8% of deaths) and average cost of these claims had increased.
Anaesthetic negligence claims involving cardiac arrest
Claims related to cardiac arrest are infrequent, with one claim per 50,000 anaesthetics, but the review emphasised that these are serious and very costly (averaging £631,000 per claim). They found that most are avoidable. 26% arose from drug errors such as unflushed cannulae, wrong drug or incorrect drug concentration. 17% arose from errors in regional anaesthesia, such as epidurals and spinals. 15% arose from airway management, such as an unanticipated difficult airway, problems with extubation, or compromised postoperative airway.
Cardiac arrest was often the endpoint for the patient in the most significant adverse event claims. A quarter of anaesthetic claims arising from cardiac arrest were associated with death, but almost two-thirds involved severe outcomes. The high cost of these compensation claims was thought to arise from cases involving hypoxic ischaemic brain injury and the associated high costs of care which are needed for patients bringing these claims.
Inadequate anaesthesia and awareness claims
Nine adults and three children made claims after inadequate anaesthesia during monitored anaesthesia care, when residual muscle relaxant drugs were accidentally given through a cannula which had not been properly flushed, leading to ‘brief awake paralysis’. These claims, following ‘brief awake paralysis’, where the patient is paralysed by muscle relaxant drugs but is aware and unable to breathe, all resulted in compensation for significant psychological distress.
The risk of brain damage and psychological injury to patients from anaesthetic drugs left in unflushed cannulas was recently investigated by healthcare watchdog, HSIB. The review highlighted a notable change in these types of claims which in 1995-2007 arose from mistakes in the operating theatre, but in the current review all arose from ward-based cannula drug-retention errors. Colour-coded labelling of drug syringes has been standardised since 2003, possibly reducing the number of patients experiencing brief awake paralysis from mistakes in induction of anaesthesia in theatre.
Anaesthetic injury after lack of informed consent
The review found that failure to obtain the patient’s informed consent was often a feature of claims relating to patients with severe outcomes. 62% of these claims arose from permanent neurological injury from regional anaesthesia. In many cases the patient had not been given an explanation of alternative treatment options to the one provided.
The review reminded anaesthetists that the 2017 Association of Anaesthetists’ guidelines emphasise that in taking informed consent for anaesthetic interventions, anaesthetists are expected to advise the patient of alternative forms of anaesthesia and pain relief.
Anaesthetic injury claims arising from monitoring failure and delay
Monitoring negligence claims included failing to identify adverse events promptly owing to poor monitoring or incorrect interpretation of monitors, and failure to detect promptly and respond to low blood pressure, resulting in neurological injury or cardiac arrest. Delay claims generally arose from delayed diagnosis, rather than organisational issues.
Compensating victims and learning from claims
NHS Resolution and the Association of Anaesthetists’ review of anaesthesia-related claims has highlighted that anaesthesia-related negligence claims are, thankfully, rare. However, when mistakes occur they are mostly avoidable, and often catastrophic for the patient. Where the patient has been permanently affected by brain injury, severe psychological injury, or fatal injury, our medical negligence team can help provide access to care, treatment and therapies, equipment, adapted accommodation and restore financial stability by claiming their entitlement to compensation.
If you would like to find out more about making a claim following severe injury caused by medical negligence, you can talk to one of our solicitors, free and confidentially, by contacting us here.