THE REPORTING OF DEATHS ASSOCIATED WITH ANAESTHESIA IN SOCTLAND

Brit. J. Anaesth. (1962), 34, 124

THE REPORTING OF DEATHS ASSOCIATED WITH ANAESTHESIA IN SCOTLAND An account of the activities of the Scottish Society of Anaesthetists in negotiating revised procedure

ROBERT LAWRIE

Perthshire General Hospitals, Scotland The Scottish Society of Anaesthetists has recently completed discussions with the Crown Office, the Scottish Department of Health, and the RegistrarGeneral for Scotland, on the subject of reporting and later recording deaths formerly described as "deaths under anaesthetics". As a result of these discussions, revised instructions on procedure to be followed have been issued by the Crown Office and the Department of Health, and the method for statistically recording these deaths in the Registrar-General's Annual Report has been amended. The details of these revised arrangements will be given later. It would, however, be appropriate at this stage to relate the arrangements as they existed prior to this revision, indicating the anomalous situations which arose from time to time, and also some of the more relevant features of our discussions. A fuller account of these now out-dated arrangements and the possible anomalies, including examples, has previously been described in an article by the author (Lawrie, 1958). THE SITUATION AS IT APPEARED

Institutional Authorities" instructing these authorities on what to do when a "death under an anaesthetic" occurs, and one to Procurators-Fiscal advising them on what to do when such a death is reported. Those to hospital authorities were last issued in 1938 and are shown in Appendix 1. These instructions seem perfectly clear and perfectly reasonable; they even specifically state that deaths occurring in these circumstances should be reported to the Procurator-Fiscal even though "not clearly attributable to the anaesthetic". Obviously there is no intention by the Crown Office that they should necessarily be labelled as deaths due to the anaesthetic. The instructions to Procurators-Fiscal on procedure to be adopted when a "death under an anaesthetic" is reported are, of course, confidential but essentially they direct that he shall "conduct an inquiry" along certain lines, the chief poiats of which are shown in Appendix 2. Again these instructions are perfectly reasonable if the patient dies under an anaesthetic. Unfortunately, however, confusion has been introduced over the years as a result of two main factors.

In Scotland, deaths which were described as "deaths under an anaesthetic" become the subject of a Procurator-FiscaPs inquiry, once they have (1) Definition of "death under an anaesthetic". been reported to the Procurator-Fiscal as such. It might seem that this should present no diffiThere is no statutory law specifically referring to culties. However, many doctors—particularly "deaths under an anaesthetic". Over the years, house surgeons present at a death following an however, since these deaths first became a matter anaesthetic, and sometimes even more experienced of interest on the grounds of public safety, the doctors—had never seen these instructions and Crown Agent, on behalf of the Lord Advocate for were therefore incapable of interpreting them. Scotland, has issued instructions concerning pro- They arrived at their own conclusions as to cedure to be adopted when such a death occurs. whether a death should be reported to the These instructions consist essentially of two com- Procurator-Fiscal under this heading and inconsisplementary parts, one to "Hospitals and other tencies and anomalies were then introduced. For 124

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BY

REPORTING OF DEATHS ASSOCIATED WITH ANAESTHESIA

(2)

The introduction of a formal written "report form". The practice of completing a report form, started in some areas, gradually spread practically throughout Scotland. This was possibly originally introduced as being a convenient way of conveying information to the Procurator-Fiscal. Its use, however, eventually appeared to have become almost a compulsory part of the proceedings, and is in fact referred to by Glaister (1953). The nature of the form was virtually the same in all areas. Headed by words to the effect that a "death had occurred under an anaesthetic" its completion represented a signed statement of fact. Apart from the personal details of the patient, the statements

made were almost entirely devoted to the anaesthetic aspects of the death. It was invariably completed, no matter what the association between the anaesthetic and the death, and formed in many areas the only "official" means of conveying the information to the Procurator-Fiscal. Whatever its original intention, therefore, in many cases it conveyed, if not a misrepresentation of the facts, an unrealistic impression of them. Once completed and received by the Procurator-Fiscal the latter had no option but to conduct an inquiry into a "death under an anaesthetic" along the lines previously mentioned. The death certificate usually included reference to the anaesthetic, and the Registrar-General in his Annual Reports (Reg. Gen. 1950-58) included a special table headed "deaths under anaesthetics (secondary cause)", the various combinations being shown in detail. The relatives, too, also received a copy of the death certificate, and no doubt drew their own conclusions. What started then as a circumstance and sometimes only a remote one, became a secondary cause of death, and it was only natural that these deaths should then be referred to as "anaesthetic deaths". In addition to these two factors, and their consequences, an added source of irritation was introduced in some areas where the ProcuratorFiscal, of necessity (for example, in country districts), had to ask for statements to be taken by members of the Criminal Investigation Department and uniformed police. This created an atmosphere almost of an inquiry into a criminal offence. This, then, appeared to be the situation when the subject was reviewed before the Scottish Society of Anaesthetists in 1957, and the Council of the Society agreed to investigate. A sub-committee was appointed to examine the situation and report. CONSENSUS OF OPINION

After full discussion the sub-committee decided that it must first substantiate the views which have been expressed. In the first instance information was obtained informally from the senior anaesthetists in charge of large departments and, after this preliminary information was considered, a questionnaire was prepared and circulated to all anaesthetists holding definite permanent appointments with the Department of Health for

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those who had seen the instructions, the description "under the influence of an anaesthetic" was almost impossible to define and various interpretations were introduced, for example: Death occurring within 24 hours of an anaesthetic; death occurring without recovery of consciousness; death occurring without recovery of reflex activity; and sometimes simply "death following an anaesthetic". Which definition was used was largely a matter of local custom but even this changed with changing personnel. In some areas ProcuratorsFiscal had conveyed their wishes and these became more or less regulations in that area. Movement of personnel from one area to another introduced conflicting interpretations, and discussions ensued. The net result was at times confusion and as a result of this even further focus was put on the anaesthetic. The instructions issued by the Crown Agent in 1938 appeared to have been lost sight of and many cases were being reported to the Procurator-Fiscal simply to be "on the safe side". In a large number of these deaths the description "under an anaesthetic" was quite unrealistic but inevitably a Procurator-Fiscal's Inquiry ensued. As the main purpose of this was specifically to inquire into the anaesthetic this further accentuated the role of the anaesthetic. Conversationally the term used in discussion, communications, etc., became simply "anaesthetic death". The whole situation seemed- to be quite unrealistic, unnecessary and at times detrimental. It appeared to be causing a certain amount of dissatisfaction which became acute at times.

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Scotland. Nineteen questions were asked, framed being described as "death under an anaesthetic" to find out principally (a) if there was general which had only incidental association with dissatisfaction and if so whether there was a desire anaesthesia. for action by the Society, (b) the variations in pro(9) The views expressed were fairly reprecedure at all stages, (c) the principal sources of sentative of anaesthetists throughout Scotland. dissatisfaction and the circumstances which could give rise to these, (d) examples of anomalous situaSUGGESTIONS FOR IMPROVING THE SITUATION tions and any other suggestions or criticisms. One Having reached these conclusions the sub-comhundred and twenty questionnaires were mittee prepared a memorandum on the subject, circulated and seventy-five were eventually combriefly outlining the problems and giving examples pleted and returned. The sub-committee carefully . of anomalies and inconsistencies. This memoranscrutinized these and arrived at the following dum concluded by suggesting that certain steps conclusions. should be taken which would have the purpose of (1) Dissatisfaction was general (over 85 per clarifying and standardizing procedure throughout cent) but a small minority preferred to leave things the country. The combined effect of these would as they were, lest more stringent regulations were at least'reduce the confusion which existed and introduced and produced the opposite effect to help to remove some of the inconsistencies and that desired. Over 80 per cent, however, were irritations which occurred from time to time. They emphatic in their desire for attempted revision by would not, in any way, interfere with the desire the Society. of the Lord Advocate to receive information, via (2) There were wide variations in interpreta- the Procurator-Fiscal, of such deaths as could tion of "death under an anaesthetic"; some of these reasonably be described as being associated with were by direction, others by discretion. The most anaesthesia. The suggested steps were: common definitions were: "deaths within 24 (1) that the Crown Agent, on behalf of the hours of an anaesthetic"; "death without recovery Lord Advocate, should revise and re-issue instrucof consciousness"; while some simply described tions to hospitals and other authorities, and them as "death following an anaesthetic". (2) that consequently he should revise and (3) There were wide variations in procedure. amend the instructions to Procurators-Fiscal; In most areas the decision to report the death was (3) that the Society should draw up a report left to the medical superintendent. In some, how- form which would more appropriately convey ever, it was left to juniors or deputies and this on information to Procurators-Fiscal and that this occasion introduced awkward and controversial should be introduced in all areas; situations. In some areas deaths were reported to (4) that the method of statistically recording the police surgeon who had indicated which cases these deaths in the Registrar-General's report should be reported to him In others they were should be amended to be in keeping with revised even reported to the local police. instructions. (4) Most areas used report forms of the type This memorandum was then shown informally indicated and this was the usual, sometimes the to the Crown Agent who was sympathetic to the only way of reporting the death. The report form problem and thought he could help along the lines caused the greatest source of dissatisfaction and suggested. He asked if an approach could be made the greatest call for revision. to him officially with the authority of the Society, (5) There was a desire for clearer and more which could be considered reasonably representawidespread authoritative information particularly tive of informed opinion. Thereafter a discussion for junior and non-anaesthetic personnel. could take place upon a possible course of action. (6) Inconsistencies were possible in the issue To this end the same sub-committee was enlarged of death certificates. and, with the approval of the Council and the (7) Minor irritations were prevalent in some Society, it was given authority to act along the areas because of police inquiry. lines suggested. The memorandum was then carefully edited (8) Examples sent in confidence were sufficient in numbers to confirm the view that deaths were and because of the technicalities involved, the sub-

REPORTING OF DEATHS ASSOCIATED WITH ANAESTHESIA

tions to hospital authorities and Procurators-Fiscal and include copies of the report form agreed upon. At the same time the Department of Health agreed to circulate all Regional Boards advising them to notify the various hospitals of procedure to be adopted and asking them to inform all surgeons and anaesthetists and other interested parties. REVISED PROCEDURE

As a result of these negotiations, early in 1961 the various revisions were formally introduced throughout Scotland. These will now be considered in more detail. Instructions to Hospital Authorities, 1961. These take the form of a letter sent by Procurators-Fiscal on behalf of the Lord Advocate, and are as follows:

DISCUSSIONS WITH THE CROWN AGENT AND THE DEPARTMENT OF HEALTH

[COPY]

Procurator-Fiscal's Office,

Finally after time for consideration by the Crown February, 1961. Agent and consultations with Procurators- Dear Sir, order to clarify and co-ordinate the procedure to Fiscal, etc., the first of two meetings was convened beInfollowed by Procurators-Fiscal in the investigation by the Crown Agent in July 1960 at the Crown of the circumstances of deaths associated with anaesOffice. Representatives of the Society and the thesia, the Lord Advocate has issued instructions to and has directed me to inform you Department of Health for Scotland attended. The Procurators-Fiscal of the necessity of reporting to me all cases of such Registrar-General was unable to send a representa- deaths which fall into the following categories: tive but sent a letter expressing his desire to help 1. Deaths which occur during the actual administration of a general or local anaesthetic, or during and making suggestions concerning classification, an operation performed under a general or local etc., in his annual report. anaesthetic: or At this preliminary meeting it was immediately 2. Deaths which are considered to be clinically due evident that our memorandum had been carefully to the anaesthetic: or studied by all concerned and there was a 3. Deaths which occur in the immediate post-operative period, ordinarily not exceeding 12 hours, unanimous desire for revision, amendment, and following a general anaesthetic from which clarification of procedure, and a completely consciousness has not been regained. sympathetic attitude to our problem. The steps They include cases where death occurs whether in suggested by the Society were accepted in the operating theatre or after removal to a ward or principle and detailed discussions ensued over room, and whether the anaesthetic was general or local, and irrespective of the anaesthetic agents and these. The technical details of most of our sugges- techniques. tions were accepted and it was left to the Crown I should be notified of such cases by telephone or Agent to draft a final revision of a letter of instruc- otherwise as soon as possible after the occurrence, and as soon as practicable thereafter on a Report Form, tions to Hospitals, Regulations for Procurators- unless I indicate that a Report is not required. The Fiscal, and a report form. These will be discussed Report Form should be signed by the operator and the anaesthetist I enclose a supply of these forms, later in more detail. and further copies may be obtained from me when In November 1960, after further consideration required. I have to remind you that in any such cases a postby all concerned, a final meeting was convened at mortem dissection should not be carried out (e.g. the Crown Office. Final drafts of the various docu- with consent of relatives) unless you have been advised ments were further discussed and every aspect of by me that a dissection at my instance is not required. I feel sure that I may expect the continued the procedure was reviewed. It was agreed that co-operation of yourself, medical and other staff, and the Crown Agent would issue amended instruc- consultants, with me and with the medical practitioners

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committee drafted a suggested letter of instructions which would suitably convey to hospital authorities the type of case which should be reported and how and when it should be reported. It also made suggestions for inclusion in revised instructions to Procurators-Fiscal. The final form of both of these, of course, rested with the Crown Agent, but it was felt that it should not be considered out of place to indicate at least the technical details. A suggested report form was also drawn up. When the sub-committee was finally satisfied with these, the completed memorandum with suggestions was formally sent to the Crown Agent. Copies were also sent to the Chief Medical Officer of Health and the RegistrarGeneral, who had been informed of these activities.

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128 who may be instructed by me to make independent inquiry. Yours faithfully, Procurator-Fiscal.

as for example through the night. Over-enthusiasm at times resulted in unnecessary reporting of cases. When such a report was received by a person, also inexperienced such as a deputy within the hospital or an assistant at the Procurator-Fiscal's office, the information that the death was "under an anaesthetic" was not disputed and the formal inquiry and written report inevitably followed. Some flexibility over the initial reporting was therefore desirable. To allow of this the first information is simply notified by word of mouth, usually by telephone, to the Procurator-Fiscal who can then decide whether an inquiry is necessary. To emphasize this further the Department of Health has asked hospitals to review procedure within individual hospitals and ensure that some specific officer is nominated for the initial reporting of these deaths to the Procurator-Fiscal, and that proper records are maintained. Regional boards and hospitals have drawn the attention of all surgeons and anaesthetists to the new instructions on procedure and by now most hospitals should have made their own internal arrangements. (d) For the first time the written instructions specifically ask for completion of a report form and its completion will, therefore, now be standard procedure throughout Scotland. A copy of this is included in Appendix 3. The new report form. The sub-committee spent a great deal of time and consideration over this and the form finally accepted was largely as it had suggested. The main aims with regard to the structure of this form were: (1) That the emphasis on the anaesthetic aspects of such a death should be a realistic one and that accordingly there should be provision for recording relevant information on all the circumstances of the death. (2) That the dual responsibility of surgeon and anaesthetist would be shown. (3) That it should be used only to report cases which could reasonably be described as being associated with anaesthesia, the three categories of death as shown in the letter to hospital authorities being restated. This is important, particularly in anticipation of the future when it may be expected that the original letter of instructions will not be fresh in everybody's memory and may not be

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This letter is not precisely as suggested by the Society but the main points suggested have been met. These are: (a) The term "death under an anaesthetic" is discontinued, thus removing any need to define this term. Also discontinued has been the term "under the influence of an anaesthetic". (b) In their place, however, the term "death associated with anaesthesia" is used. Three categories of death are shown which, it was agreed, would realistically and adequately describe the association with anaesthesia and so satisfy both clinical and fiscal responsibility for the conduct of an inquiry. No difficulty was experienced in defining categories 1 and 2 but considerable discussion took place on category 3. This, as originally phrased, did not include the phrase "ordinarily not exceeding 12 hours". Without such a phrase, however, the Crown Agent considered the wording too indefinite, particularly in view of the fact that in some areas ProcuratoTS-Fiscal asked that all "deaths occurring within 24 hours" should be reported without any modifying factors such as failure to regain consciousness. The Society's representatives were against any inclusion of a time factor but eventually agreed that, provided the term used did not simply state all deaths occurring within 12 hours, some formula could be arrived at to satisfy both. Eventually "ordinarily not exceeding 12 hours" was accepted as this did not inevitably include all deaths occurring within 12 hours, but ordinarily excluded those outwith 12 hours unless they come into category 2. Also the governing phrase "from which consciousness has not been regained" further greatly modifies the category, and time alone, therefore, is not the deciding factor. Although this category may not be perfect it was felt it was at least realistic and practical and, therefore, reasonable. (c) As mentioned previously, one of the greatest sources of controversy has been the fact that the decision to report a case in the first instance was incorrect. Many of these deaths occur at a time after anaesthesia when the house surgeon, or some other person inexperienced in the procedure, is on duty, and "in charge" of the case,

BRITISH JOURNAL OF ANAESTHESIA

REPORTING OF DEATHS ASSOCIATED WITH ANAESTHESIA

Amended Regulations for Procurators-Fiscal and their significance. The third of our suggestions—the amendment of Regulations for Procurators-Fiscal—affects principally instructions of a confidential nature between the Lord Advocate and ProcuratorsFiscal. It would not be appropriate here, therefore, to discuss these in detail. Extracts, however, have already been promulgated by regional boards and three points arising from these are relevant and significant. (1) It is advised that the "independent medical man" conducting the medical investigation should be "experienced in the use of anaesthetics or in pathology". This requires no comment except that it is an innovation.

(2) As the Procurator-Fiscal will have received relevant information on the report form, it will not now be considered necessary in the majority of cases to direct police inquiry. This, therefore, should reduce one of the minor irritations expressed earlier. (3) The medical investigator is asked to direct his attention to the following points: (i) whether the patient was medically examined before operation or the administration of an anaesthetic; (ii) whether all precautions were observed in the actual administration of the anaesthetic; (iii) whether there were any factors present which could have been discovered by examination, indicating that the administration of an anaesthetic would be attended with special risk to life; (iv) whether the patient was kept under constant medical or nursing care during the period following the operation. The first three of these questions are largely as framed in previous regulations. Question 3, however, formerly used the words "might or ought to have been discovered"—"could" was considered less incriminating and is now substituted in their place. Question 4 is an additional question and worthy of comment because of its significance. It was originally suggested by Procurators-Fiscal that it should be included in the report form. In view of its implications, however, it was thought that any answer other than "yes" would be incriminating and therefore a certain reluctance as to its completion would naturally occur. Any direct positive or negative would be difficult to give in many cases. Because of its importance, however, it was suggested that its inclusion was more appropriate in the points the medical investigator was asked to ascertain. It is well that anaesthetists should know of this question; most will already be conversant with the others. Its inclusion may help to add weight to the plea so often expressed that the immediate postoperative period is a particularly critical one. There was considerable discussion over this—it was a last-minute suggestion which the Society could only agree was a realistic one. Under the circumstances there was relief that it had not been included in the report form, but satisfaction that its inclusion somewhere in

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always available to the persons concerned. The fact that these forms are now, however, distributed by Procurators-Fiscal should obviate this difficulty. (4) To ensure that all interested parties are consulted. (5) To avoid confusion over the completion and issue of the death certificate. It was considered that the final form arrived at fulfilled these requirements. It might be argued that the formal introduction of such a report form renders the procedure unnecessarily elaborate. It should be remembered, however, that completion of some type of form had become accepted practice in most areas. The introduction of this present form, therefore, ensures that inconsistencies will not be reintroduced in attempts to convey written information in a way which is misleading. As will be mentioned later, it also reduces the need for statements being taken by uniformed police. Although completion of it is asked for by Procurators-Fiscal, it is not in any way a statutory form. Mistakes and omissions in its completion in whole or in part are not in any way irrevocable or incriminating. The Crown Agent was very particular to point this out repeatedly. The main purpose of the report form is largely one of convenience although at first sight the reverse may appear to be the case. Although not intended as such, a copy of the completed form provides a convenient way of keeping a record of these deaths' for future reference in individual hospitals or departments, or in even larger groupings.

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130 TABLE I

Number of deaths described as being primarily due to either (1) Therapeutic Misadventure in Anaesthesia, or (2) complications of Anaesthesia for nontherapeutic purposes. 1950

1951

1952

1953

1954

1955

1956

1957

1958

1959

6

2

3

2

8

4

0

4

1

0

Ameruled classification. The fourth suggestion was that there should be a revision of the manner of presenting these deaths statistically in the Annual Reports of the RegistrarGeneral. These were formerly shown— "Table 41c—Deaths under Anaesthetics" (Secondary Cause) Those deaths where the anaesthetic was the primary cause were shown separately under the general classification of all deaths according to International Detailed List of Causes. In the latest Report for 1959 (Reg. Gen. 1959), deaths formerly described as "Under Anaesthetics" are now shown— "Deaths connected with administration of Anaesthetic" "(mention of Anaesthetic other than primary cause)" and the table now includes under separate headings "Deaths in which Anaesthetics were certified as the primary cause". The amended classification is in keeping with the other revisions. It is interesting to note in this respect that in the Annual Reports issued in' the years immediately preceding the start of our discussions, there had been a steady rise in the number of "Deaths under Anaesthetics" (168 in 1956). Since 1956 there has been a sharp and sustained drop. In 1959 (under the new heading) the figure is 124. As evidence of the fact that the anaesthetist or anaesthetic is given the benefit of the doubt in the vast majority of cases as regards the primary cause, the figures given in table I may be of interest. No further comment is indicated! CONCLUSION

In Scotland when a death occurs in circumstances in which it is considered there has been an

"association with anaesthesia", worthy of inquiry by the Procurator-Fiscal, these circumstances are now described on what is considered to be a rational basis. The procedure thereafter should be perfectly straightforward and standard. Information and instructions have been made available for all persons likely to be involved. It is hoped, therefore, that by clarification and standardization, the practice of reporting deaths to the ProcuratorFiscal and the subsequent inquiry which will ensue, will in most cases simply be a formal way of carrying out our responsibilities in this respect. There should be less confusion and discussion on occasion and consequently less publicity. As hitherto only when the Procurator-Fiscal considers that unusual circumstances are present will anything in the nature of a public inquiry result, and this will be at the discretion of the Lord Advocate. The Procurator-Fiscal's Inquiry is of a confidential nature and in addition to safeguarding th<* public interest without unnecessary publicity, it also provides a safeguard to the clinician. The very fact that such an inquiry has been conducted should safeguard anaesthetist and surgeon against misdirected attempts at litigation. The discussion and explorations have been somewhat protracted—the first committee met in April 1957 and the results were put into practice in February 1961. The main reason for such a long interval has been essentially due to the interests of the many parties involved. No step has been taken without reference to the Council, and through them, the members of the Scottish Sodety. Similarly full discussion between the Crown Agent and Procurators-Fiscal has taken place. ACKNOWLEDGMENTS

On behalf of the sub-committee of the Scottish Society of Anaesthetists I would like to express thanks and appreciation for the help and friendly co-operation of the Crown Agent, Procurators-Fiscal, the Department of Health for Scotland, and the RegistrarGeneral for Scotland. I would also like personally to thank Dr. R. N.

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the investigation was fair if somewhat disconcerting.

REPORTING OF DEATHS ASSOCIATED WITH ANAESTHESIA Sinclair and Dr. M. Shaw of Glasgow for all the work they put into these negotiations, particularly as members of the original exploratory sub-committee, and Dr. John Gillies (Edinburgh), Dr. W. M. Shearer (Dundee), and Dr. A. Raffan (Aberdeen), who completed the final executive sub-committee. REFERENCES

APPENDIX 1 Crown Office, Edinburgh, 1. 14th April, 1938. DEATHS UNDER

ANAESTHETICS

The reporting of deaths occurring while patients are under the influence of an anaesthetic has been under further consideration of the Crown Authorities with a view to clearing up doubts raised by certain Institutional Officials. As a result, the Lord Advocate has instructed me to -direct your attention to the matter and to advise you that the necessity for reporting such deaths to the Procurator-Fiscal applies to all cases where death occurs during anaesthesia whether in the Operating Theatre or after removal to the ward or room. This applies to cases so occurring even although the explanation of the death may be clearly attributable to the condition of the patient apart altogether from anv question of an anaesthetic factor. Such cases fall to be reported whether the anaesthetic be a general anaesthetic administered by inhalation or by injection into the blood stream (i.e. Evipan) or spinal canal (i.e. spinal anaesthetic drugs) or per rectum (i.e. Avertin) or to be cases of some combination of such drugs with local anaesthesia. So too cases of deaths occurring while the patient is under the influence of a local anaesthetic fall to be reported to the Procurator-Fiscal. APPENDIX 2 EXTRACT FROM REGULATIONS TO BE OBSERVED BY PROCURATORS-FISCAL

To enable the independent medical man to prepare his report, Procurators-Fiscal will submit to him the precognitions taken from persons present when the anaesthetic was administered and ask him to direct particular attention to the following points, viz.: 1. Whether the patient was medically examined before it was decided that an anaesthetic should be administered. 2. Whether ajl due precautions were observed in the actual administration of the anaesthetic. 3. Whether there were any symptoms about the patient which might or ought to have been discovered by examination, indicating that the administration would be attended with special risk to life.

APPENDIX 3

REPORT TO PROCURATOR-FISCAL OF DEATH ASSOCIATED WITH ANAESTHESIA AND/OR OPERATION

(See Notes overleaf) Sir, We hereby report the death of at (Hospital. Nursing Home, etc.) on (date) which was associated with anaesthesia and/or operation (see Note 1). 1. Full Name Age Ward Home Address 2. Date admitted to Hospital, and time 3. Nature of Disease, Injury or Ailment for which the operation was advised 4. Was formal consent for operation and administration of anaesthetic obtained? 5. Was the operation of an Elective or Emergency nature? 6. Note on clinical findings of examination of Heart, Lungs and Urine. 7. Note on any concurrent pathological condition or ailment present, or other relevant pre-operational details. 8. What precautions and medicaments were used in preparing the patient for anaesthesia and the surgical or other procedure? Where applicable give quantities and times. 9. Anaesthetic: Date and Time: Administration started stopped Details of agents and techniques used, including sequence and quantities. Remarks: Anaesthetist: 10. Operations: Date and Time: Started Finished Nature of operation proposed, performed, or in progress: Remarks: Operator: 11. Date, Time and Place of Death (i.e. Theatre, Ward, etc.) 12. Details in chronological order of events immediately preceding death and of resuscitative measures undertaken. 13. Opinion as to cause of Death, and any other general observations on the case: — Date Signature (Operator) Signature (Anaesthetist) The Procurator-Fiscal Notes: 1. Only deaths, the circumstances of which fulfil any one or more of the following conditions, should be reported on this form, viz.:

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Glaister. J. (1953). Medical Jurisprudence and Toxicology, 9th ed., p. 620. London: E. and S. Livingstone Ltd. Lawrie, R. (1958). Deaths under an anaesthetic. Brit. J. Anaesth., 30, 85. Registrar-General (1950-58). Annual Report of the Registrar-General for Scotland. H.M.S.O. (1959). Annual Report of the Registrar-General for Scotland. Table 41c, p. 159. H.M.S.O.

F.89

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(a) Deaths which occur during the actual administration of a general or local anaesthetic; or (b) Deaths which are considered to be clinically due to the anaesthetic; or (c) Deaths which occur in the immediate postoperative period ordinarily not exceeding 12 hours following a general anaesthetic from which consciousness has not been regained. 2. Whenever practicable this form should be completed in consultation with any other Medical

practitioner specially concerned or specifically mentioned and forwarded to the Procurator-Fiscal as soon as possible. 3. The Death Certificate must not be issued until instructions have been received from the Procurator-Fiscal or his representative. 4. The completion of Question 13 is a matter of discretion; while it is to assist the ProcuratorFiscal and his Medical Adviser to arrive at a certifiable cause of death, it is not in itself the certified cause of death.

AWARENESS DURING SURGERY

Sir,—Every anaesthetist must be interested in Dr. Hutchinson's investigation into "Awareness during surgery" (Brit. J. Anaesth., 33, 463), and I am sure there must be many unrecorded instances. I have had three recent complaints from patients—all females. One I discount: she is a very nervous introspective dental nurse, who has had a great deal of surgery, and is going to have a great deal more. The second was aware of being painted before being draped, and I think at the time she was not properly under, but she remembers; while the third has quite a convincing tale, but without horror or discomfort, only the awareness that she was being operated upon part of the time. The remarkable thing is that with ordinary monitoring by pulse and blood pressure no sign is forthcoming, and it obviously does no harm provided the patient does not remember. Hyoscine has the reputation of causing a retrograde amnesia, and if I have any doubt as to the depth of anaesthesia at any point of the surgical procedure I inject 1/150 grain of hyoscine intravenously before the end of the operation; e.g. it is my custom to "flood" patients during Caesarean section with oxygen as the baby is being extracted, and on one occasion the extraction being a little prolonged the patient opened her eyes and looked up into my face and closed them again—I gave her hyoscine and she has no recollection, not even a bad dream to relate.

Using methohexitone sodium, which I use almost exclusively for induction, patients sometimes complain after a short procedure of having had a dream, not necessarily a bad dream, but frequently unpleasant, as one woman said she was in a vile temper and was chastising her children unmercifully, but the dream is never connected with the surgery. The important thing, however, is that awareness during surgery does not in any way endanger the patient, and tie memory can be blotted out with hyoscine. J. SHEGOG RUDDELL

Lethbridge, Alberta, Canada

THIOPENTONE REQUIREMENTS

Sir,—In their article "Effects of premedication with phenothiazine derivatives" (Brit. J. Anaesth., 1961, 33, 382), J. W. Dundee and J. Moore refer to an article written by us "Pre-anaesthetic medication with chlorpromazine: a comparison with morphine" (Acta anaesth. scand., 1958, 2, 133), and state that we "found no difference between thiopentone requirements after chlorpromazine 50 mg or morphine 10 mg . . . ". From this the average reader is en tided to think that we have come to a conclusion regarding thiopentone requirements in our study. In fact, we did not write anything about thiopentone requirements and had little opportunity of examining this question since, as pointed out in our article, all

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CORRESPONDENCE