Inquest into the death of Ricky Ryder

Contributing factors

• delay of operation from Friday 21 April to Saturday 22 April 2006
• underestimation of bleeding risk by junior surgical registrar
• failure of consultant surgeon to examine patient preoperatively
• failure of consultant surgeon to be present at start of operation
• failure to check that blood had been group & held
• failure to arrange cross-matched blood preoperatively despite known arterial bleeding on admission
• inadequate draping of surgical field to allow quick access to femoral artery
• prolonged time (40 minutes) to control active bleeding
• failure of anaesthetist to call for senior help despite patient deterioration
• failure to use O-negative blood available in emergency department
• delay in obtaining blood due to incorrect completion of blood request forms
• anaesthetist not aware of availability of O-negative blood or location in emergency department
• anaesthetist not aware she could call for help from consultants not on-call
• poor communication between anaesthetist and surgeons during operation
• lack of phone in theatre requiring staff to leave to make calls
• lack of additional nursing staff when second emergency case arose
• inadequate nursing support due to anaesthetic nurse taking lunch break
• underestimation by all teams of seriousness of unfolding situation
• high staff turnover leading to unfamiliarity with local procedures and resources
• lack of dedicated emergency theatre resulting in scheduling delays
• inadequate preoperative assessment of bleeding risk

Coroner's recommendations

1. Blood cross-matched when requested should always be checked as available prior to commencement of any surgical procedure where major vascular injury is suspected
2. Anaesthetic registrars must be instructed of the importance to call for additional help at the earliest possible time rather than attempt to manage situations for which two anaesthetists would be better than one
3. Surgical supervision should be provided for all inexperienced registrars; Alice Springs Hospital should consider taking only second year Advanced Trainees for this rotation
4. Additional emergency surgical lists should be provided during the week and the rostering of nursing staff across weekends needs to be considered in light of safe working hours and practice
5. Senior surgeon will review all surgical patients before surgery; if determined that a surgical registrar will complete the case, the senior surgeon will be available for supervision and assistance at all times
6. Code Blue button in theatre to be serviced regularly and theatre staff educated in its use
7. A telephone will be placed in all theatres to avoid the need to leave theatre in an emergency
8. An in-service of the use of rapid infuser will be held for all theatre staff; consideration will be given to the purchase of a second rapid infuser to be stored in theatre
9. Theatre begin on time
10. Increase in ICU beds where required with resources to increase staff
11. All theatre staff, especially nursing staff, to be adequately trained and have theatre certification
12. A 'right person, right site' policy with 'time out' procedure to be operated in theatre
13. Northern Territory Government should fund a dedicated emergency theatre for Alice Springs Hospital as a matter of priority