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Ignoring an alarm is a life-threatening risk.

Published

20 March 2025

Read time

4 minutes

Due to negligence in anesthesia monitoring by healthcare professionals, a patient ends up in a chronic vegetative state.

Experience feedback following a cardiorespiratory arrest in the operating room with prolonged cerebral hypoxia (more than 10 minutes): dramatic consequences, analysis of human and technical causes, and improvement areas for anesthetic safety.

Analysis of a case of failure in anesthesia monitoring

In this article, you will follow the case of a gynecological surgical intervention that turned into a cardiorespiratory arrest with prolonged cerebral hypoxia.

A 23-year-old patient presented for a scheduled surgical procedure combining a biopsy curettage and a laparoscopy for pelvic pain. During the procedure performed under general anesthesia, a serious incident occurred: the ventilation machine was accidentally disconnected. At this critical moment, neither the gynecologist-obstetrician nor the anesthesiologist-intensivist were present in the operating room.

The staff present, absorbed in their respective tasks, unfortunately did not react to the audible alarms emitted by the anesthesia equipment.

This situation led to a cardiorespiratory arrest with prolonged cerebral hypoxia, exceeding 10 minutes. The patient had to be transferred to intensive care for the management of anoxic coma. The consequences of this incident have been dramatic: the patient is now in a chronic evolving vegetative state, requiring total dependence for all activities of daily living.

The physical and psychological integrity impairment (PPII) has been evaluated at 99%.

Chirurgie

What are the legal consequences?

In terms of criminal law, the gynecologist was prosecuted for unintentional injuries, the consequences of which resulted in a total incapacity to work for more than three months. This procedure ended with a recognition of guilt and a conviction.

At the same time, a civil action was brought against all parties involved in the care, aiming to establish their respective responsibilities and obtain compensation for the damage suffered.

Two separate legal proceedings have been initiated.

The distribution of responsibility

To accurately determine the share of responsibility of each party involved, a judicial expertise was carried out. The judicial experts detailed in their report the shares of responsibility of each party as follows:

20% for the establishment

To the extent that experts consider that the staff showed a lack of responsiveness to the audible alarms of the anesthesia equipment, and made a mistake regarding the decision to mobilize the patient without a doctor present;

60% for the gynecologist

In view of a poor surgical indication, and the surgical assistant who also did not respond to audible alarms.

20% for the anesthesiologist-intensivist

To have abandoned his patient when constant presence was necessary and required by regulations.

The determining factors of the incident

Several critical points have been identified regarding the management of patients under anesthesia:

  • Lack of responsiveness to the audible alarms of the anesthesia equipment.
  • Lack of monitoring of the patient by staff and practitioners.
  • Absence of practitioners.
  • Mobilization of the patient by the staff without the presence of a doctor.

Our recommendations

Shared responsibility

It is recommended that the surgeon and anesthesiologist, whose simultaneous presence is essential, jointly assume responsibility for the two-stage surgical intervention, patient positioning, and management of postural complications during surgery.

Continuous presence of the anesthesiologist

The continuous presence of the anesthesiologist is essential, their absence from the operating room being considered as abandoning the patient without supervision.

Explicit agreement from the surgeon

Although the surgeon retains his role as team leader in the operating room with the staff under his responsibility, any relocation of the patient requires the presence or explicit agreement of a practitioner.

Checking the connections

Particular vigilance must be maintained regarding the continuous verification of the machine connections throughout the intervention.

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