Rachel Gibson · Prevention of Future Deaths report

On 20 July 2022 I commenced an investigation into the death of Rachel Gibson, age 47. The investigation concluded at the end of the inquest on 21 August 2024. The conclusion of the inquest was:

Medical Cause of Death:

1a Hypoxic-Ischaemic Brain Injury
1b Cardiorespiratory arrest caused by infiltration of local anaesthetic during surgery
1c Right hip replacement (April 2022)

Narrative conclusion:

Rachel Gibson sustained irreversible brain damage following cardiac arrest caused by administration of excessive local anaesthetic (Ropivacaine) during surgery.

Dr Rachel Gibson had severe osteoarthritis and underwent hip replacement surgery at Spire Lea Hospital, Cambridge on 12 April 2022. Towards the end of the procedure an infiltration of Ropivacaine was used in excess of the recommended dose. Upon return to her room she suffered an unwitnessed cardiac arrest. She was resuscitated and transferred to Addenbrooke’s Hospital where she was found to have sustained irreversible brain damage. She died at Addenbrooke’s Hospital on 14 July 2022.

The evidence was that it is routine practice before the procedure for the anaesthetist to give oral instructions to the scrub nurse specifying the type and dose of local anaesthetic to be used to infiltrate the operative site. Towards the end of the operation the scrub nurse hands the local anaesthetic to the surgeon who then carries out the infiltration.

The intention in this case was for a 0.2% solution of Ropivacaine to be diluted 50/50 with normal saline before it was infiltrated. The evidence suggested that this was not done. The result was that excessive Ropivacaine was administered by mistake.

The evidence at the inquest was that this type of practice is common nationally.

1. The responsibility for checking and administering the local anaesthetic is unclear:

1. The instruction was given orally and not written down by the anaesthetist (the prescriber).

2. The anaesthetist did not check what the nurse had written down.

3. The nurse drew up the local anaesthetic from a stock bag and checked this with another nurse, but not with the anaesthetist.

4. The nurse then handed the drawn-up anaesthetic to the surgeon to administer.

2. There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams. This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced.

3. The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation. However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation. This is why I believe I am under a duty to draw it to your attention.