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Precis

Charge:  

The Director of Proceedings charged that Dr Rajasingham, in the course of his anaesthetic management of a patient, was guilty of professional misconduct. The particulars of the charge were that he failed:

1. To monitor or adequately monitor the patient while she was under anaesthetic and in particular failed to monitor urine, blood pressure and temperature.
2. To ascertain whether the central line was correctly placed or sited and/or was functioning appropriately.
3. To communicate adequately to the orthopaedic surgeons and/or radiographer that he was concerned about the wellbeing and safety of the patient when there were indications by at least 4.30am on 12 December 1996 that her wellbeing and safety was being compromised.
4. At any time to discuss with the orthopaedic surgeons the need for a catheter to be inserted to enable him to monitor the urine output of the patient.
5. To review at any time the decision not to insert a catheter despite a continuous need to monitor IV fluid replacement and the instability of vital signs including those related to cardiac output.
6. To take appropriate steps when he became concerned or ought to have become concerned about the patient's wellbeing.

Background: 

The patient was involved in a motor vehicle accident late in the afternoon of 11 December 1996. She had at least 13 fractures which were largely confined to her legs although there were some fractures of her hands. At 11.20 pm she was transferred to the Operating Theatre where she was operated on by an orthopaedic surgeon. Dr Rajasingham was the anaesthetist for the operation.

The operation was intensive and continued throughout the night. Around 4.30am Dr Rajasingham became concerned about the patient's condition. He asked the surgeons to hurry and at the end of the operation asked the surgeon, to percuss the chest. Dr Rajasingham had some concerns about the patient's condition and was suspicious that the CV line that had been changed may have been in the wrong place and that her condition was related to that. Dr Rajasingham had asked the radiographer to take an x-ray of the patient's chest in theatre but was advised that that was not possible.

Once the operation was completed the patient was moved into intensive care and an x-ray was taken which showed there was bleeding occurring into the chest cavity. Dr Rajasingham inserted a chest drain and the blood was drained. By 8.15am it was thought that the patient had improved, but within an hour, she required further resuscitation. More intrathoracic drains were inserted but the patient did not respond to the resuscitation.

Finding:

The Tribunal found Dr Rajasingham not guilty of professional misconduct.

When considering particulars 1 and 5, the Tribunal accepted it would have been more desirable to have a urinary catheter inserted at the pre-operative stage, but that Dr Rajasingham's decision not to insert the catheter when the patient was presented in theatre was a reasonable decision based on the circumstances at the time and accordingly did not fall short of an acceptable standard. The Tribunal considered Dr Rajasingham did monitor temperature.

The Tribunal was satisfied particular 2 was not established. When inserting the central line for the second time, Dr Rajasingham satisfied himself that it was correctly sited by aspirating blood and then filling a four lumen catheter with heparinized saline. By that action, Dr Rajasingham was satisfied as to the appropriate placement of the CV line. It was only when he became concerned around 4.30am that he considered the possibility of the line being in the wrong place. At that stage, he did ask the surgeon to hurry up and finish, sought an x-ray and asked the surgeon to assist him to percuss the chest. The Tribunal considered that those actions were appropriate in the circumstances.

When considering particulars 3, 4 and 6 the Tribunal was satisfied that there was little communication about the management of the patient between the surgeon and Dr Rajasingham. It is the Tribunal's view the surgeon was ultimately responsible for the patient's care, and there was little communication between the pre-operative team and the surgeons and anaesthetist. The Tribunal considered this was certainly not an ideal situation. However it was satisfied that Dr Rajasingham did attempt to communicate with the surgeons and with the radiographer to assist in the management of the patient and considered it difficult to see how, without the co-operation of the surgeons and radiographer, Dr Rajasingham could have done any more.

The Tribunal hoped that the reviews that have taken place in respect of the tragic death of the patient have resulted in internal changes to the procedure and a recognition of the need to have in place procedures to deal with trauma patients. It considered the management of the patient on arrival in the Emergency Department at Rotorua Hospital appeared to have been characterised by an underestimation of both her state and her injuries - and that was an underestimation that permeated her management throughout. The Tribunal was satisfied that to single out Dr Rajasingham as playing the major role in the tragic outcome for the patient and her family was not borne out by the circumstances at the time or the opinions of the medical witnesses who reviewed Dr Rajasingham's actions.