Learning from the law: a review of 21 years of litigation for anaesthetic negligence resulting in peripartum hypoxic ischaemic encephalopathy.

One of the most devastating complications that can result from medical mismanagement during labour and delivery is hypoxic ischaemic encephalopathy. Hypoxic ischaemic encephalopathy has profound implications for the newborn and its family, as well as for the healthcare team involved. Hypoxic ischaemic encephalopathy can take only minutes to develop, but the repercussions of this complication can last a lifetime. A proportion of these injuries arise from failure to deliver the baby within a sufficiently short time frame once fetal compromise has been recognised. Obstetric anaesthetists are often involved in such claims, usually in relation to a perception that provision of anaesthesia for caesarean section was unduly delayed. In the following article, using a database of over 360 cases spanning 21 years, we break down and examine the recurrent components of medicolegal claims concerning the anaesthetic involvement in hypoxic ischaemic encephalopathy, and consider how increased awareness of the anaesthetic contribution to this complication might reduce future harm, improve clinical standards and consequently decrease the need for litigation.

Regional anaesthesia: risk, consent and complications.

The risks of regional anaesthesia relate primarily to the technical nature of the procedure, chief among them being neurological. While rare, the direct relationship between nerve damage and the procedure itself means that patients need to be aware of this complication when consent is sought. In order to give valid consent, a patient must be informed. The extent of the information required has been defined by a 2015 legal ruling which established that the standard is the expectation of a reasonable patient, rather than the information deemed consequential by a reasonable doctor. The implications of this for clinicians are profound, and mean that the process of consent must, for example, include alternatives to the proposed treatment. Additionally, patients must have capacity and give their consent without coercion. Effective communication of risk can be challenging. As well as the barriers to comprehension that can result from language, literacy and numeracy, clinicians need to be aware of their own biases, often in favour of a regional anaesthetic approach. Patients also have biases, and doctors must be aware of these in order to best target their provision of information. Careful use of language and employing adjuncts such as information leaflets and visual aids can help to maximise the individual's autonomy. Particular care must be taken in special situations such as where patients have capacity issues or time is limited by the emergency nature of the intervention.

Learning from the law. A review of 21 years of litigation for nerve injury following central neuraxial blockade in obstetrics.

Medicolegal claims for neurological injury following the use of central neuraxial blockade in childbirth represent the second most common claim against obstetric anaesthetists. We present an analysis of 55 cases from a database of 368 obstetric anaesthetic claims. Common themes that emerge from the analysis include: consent; nature of nerve injury (non-anaesthetic; direct; chemical; compressive); recognition; and management. Specific advice arising from these cases includes: the importance of informing patients of the risks of nerve damage; keeping below the conus of the cord for intrathecal procedures; responding appropriately if a patient complains of paraesthesia; and having a high index of suspicion if recovery of normal neurological function is delayed. As ever, principles of good practice, including respect for patient autonomy, early provision of information, good communication and a high standard of record-keeping, will minimise the frustration of patients that can then lead them to seek a legal route to redress if they suffer an injury following central neuraxial blockade.

Learning from the Law. A review of 21 years of litigation for pain during caesarean section.

The large majority of caesarean sections in the UK are now carried out under neuraxial anaesthesia. Although this technique is widely accepted as being the safest option in most circumstances, the use of regional anaesthesia increases the risk of patients experiencing intra-operative discomfort or pain. Pain during operative obstetric delivery is the commonest successful negligence claim relating to regional anaesthesia against obstetric anaesthetists in the UK. In the following article, using a database of over 360 cases spanning 21 years, we break down and examine the recurrent components of medicolegal claims concerning pain during caesarean section and consider how anaesthetists might avoid litigation.