Deaths on the table: Proposal for an international convention on the investigation and prevention of anaesthetic mortality

Medicine and Law

Volumn 17, Issue 1, 1998, Pages 31-54

  Faunce, T A ^a,b   Rudge, B ^c  

^a AUSTRALIAN NATIONAL UNIVERSITY   (Australia)

^b Supreme Ct Australian Cap Terr ^*  (Australia)

^c CANBERRA HOSPITAL   (Australia)

Author keywords

Anaesthetic mortality; Human rights; Medical Professional Regulation

Indexed keywords

ANESTHESIA; ANESTHETIC EQUIPMENT; ARTICLE; AUSTRALIA; CIVIL DEFENSE; CLINICAL PRACTICE; CONFIDENTIALITY; CORONER; CRIMINAL JUSTICE; DEATH; DEATH CERTIFICATE; FORENSIC MEDICINE; HUMAN; HUMAN RIGHTS; MALPRACTICE; MEDICAL ETHICS; MEDICAL LIABILITY; MEDICOLEGAL ASPECT; MONITORING; MORTALITY;

EID: 0032452598     PISSN: 07231393     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (146)

1. Aristotle, Poetics (ed D.W. Lucas) (1968)
2. G. Steiner, The Death of Tragedy (1961) at 302. "We have jettisoned a good deal of sentimentality, and something of the hysteria of grief by which the living nourish their own egocentric emotions under pretext of mourning, or attempt some shameful compensation for injury or neglect..." T.R. Henn, The Harvest of Tragedy (1956) at 262.
3. G. Steiner, The Death of Tragedy (1961) at 302. "We have jettisoned a good deal of sentimentality, and something of the hysteria of grief by which the living nourish their own egocentric emotions under pretext of mourning, or attempt some shameful compensation for injury or neglect..." T.R. Henn, The Harvest of Tragedy (1956) at 262.
4. C.C.P Eagle and N.J. Davis, "Report of the Anaesthetic Mortality Committee of Western Australia 1990-1995" (1997) 25 Anaesth Intens Care, 51 at 56.
5. H.K. Beecher and D.P. Todd, "A Study of the Deaths Associated with Anesthesia and Surgery Based on a Study of 599,548 Anesthesias in Ten Institutions 1948-1952, Inclusive" (1954) 140 Ann Surg 2. One of the first patients to die as a result of anaesthesia was Hannah Greener in 1848. She perished while having surgical drainage of an infected toe, after inhaling chloroform. J.H. Eichhorn "Historical Perspective" in J.H. Eichhorn (ed), Anaesthesia Patient Safety. A Modern History. Selections From the Anesthesia Patient Safety Foundation Newsletter (1995) al 1.
6. H.K. Beecher and D.P. Todd, "A Study of the Deaths Associated with Anesthesia and Surgery Based on a Study of 599,548 Anesthesias in Ten Institutions 1948-1952, Inclusive" (1954) 140 Ann Surg 2. One of the first patients to die as a result of anaesthesia was Hannah Greener in 1848. She perished while having surgical drainage of an infected toe, after inhaling chloroform. J.H. Eichhorn "Historical Perspective" in J.H. Eichhorn (ed), Anaesthesia Patient Safety. A Modern History. Selections From the Anesthesia Patient Safety Foundation Newsletter (1995) al 1.
7. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
8. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
9. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
10. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
11. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
12. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
13. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
14. R.A. Hingson, W.D. Holden, A.C. Barnes, "Mechanisms Involved in Anesthetic Deaths. A Survey of Operating Room and Obstetric Delivery Room Related Mortality in the University Hospitals of Cleveland, 1945-1955." (1956) 56 NY State J Med 230. B.S. Clifton and W.J.T. Hotten, "Deaths Associated With Anaesthesia" (1963) 35 Br J Anaesth 250. F.M.S. Bodlander, "Deaths Associated with Anaesthesia" (1975) 47 Br J Anaesth 36. G.G. Harrison, "Death Attributable to Anaesthesia: a 10-year Survey (1967-1976)" (1978) 50 Br J Anaesth 1041. K.W. Turnbull, P.F. Fancourt-Smith, G.C. Banting, "Death Within 48 hours of Anaesthesia at the Vancouver General Hospital" (1980) 27 Can Anaesth Soc J. 159. A Hovi-Viander, "Deaths Associated With Anaesthesia in Finland" (1980) 52 Br J Anaesth 483. L. Tiret et al, "Complications Associated with Anaesthesia- a Prospective Survey in France" (1986) 33 Can Anaesth Soc J. 336. M.C. Derrington and G. Smith, "A Review of Studies of Anaesthetic Risk, Morbidity and Mortality" (1987) 59 Br J Anaesth. 815.
15. T. Pedersen "Mortality Associated with Anaesthesia" in A.R. Aitkenhead (ed), Baillière's Clinical Anaesthesiology International Practice and Research-Quality Assurance and Risk Management in Anaesthesia (1996) vol 10(2) at 237.
16. J.B. Cooper, R.S. Newbower and R.J. Kitz, "An Analysis of Major Errors and Equipment Failures in Anaesthesia Management- Considerations for Prevention and Detection" (1984) 60 Anaesthesiology 34.
17. Study of 750 cases of anaesthetic related deaths reported to the UK Medical Defence Union 1970-1982 in: J.E. Utting, "Pitfalls in Anaesthetic Practice" (1987) 59 Br J Anaesthesia. 877.
18. R.L Keenan, "Anaesthetic Mortality" (1992) 11(2) Seminars in Anaesthesia 89 at 92. The Canadian Anaesthetists Society published guidelines requiring pulse oximetry and capnography in 1989 and 1990 respectively. The Association of Anaesthetists of Great Britain and Ireland "strongly recommended" these devices in 1988. The American Society of Anesthesiologists mandated pulse oximetry in 1990 and "encouraged" the use of capnography in 1993. The Australian and New Zealand College of Anaesthetists, required pulse oximetry and capnography to be "exclusively available" from 1989 and 1992 respectively. See J.M Davies and R Robson, "The View from North America and Some Comments on "Down Under"" (1994) 73 Br J Anaesthesia, 105.
19. R.L Keenan, "Anaesthetic Mortality" (1992) 11(2) Seminars in Anaesthesia 89 at 92. The Canadian Anaesthetists Society published guidelines requiring pulse oximetry and capnography in 1989 and 1990 respectively. The Association of Anaesthetists of Great Britain and Ireland "strongly recommended" these devices in 1988. The American Society of Anesthesiologists mandated pulse oximetry in 1990 and "encouraged" the use of capnography in 1993. The Australian and New Zealand College of Anaesthetists, required pulse oximetry and capnography to be "exclusively available" from 1989 and 1992 respectively. See J.M Davies and R Robson, "The View from North America and Some Comments on "Down Under"" (1994) 73 Br J Anaesthesia, 105.
20. R. Holland, "Anaesthetic Mortality in New South Wales" (1987) 59 Br J Anaesth, 834. J.C. Warden, C.L. Borton, B.F. Horan, "Mortality Associated with Anaesthesia in NSW, 1984-1990" (1994) 161 Med J Aust 585. J.C. Warden and B.F. Horan, "Deaths Attributed to Anaesthesia in New South Wales, 1984-1990" (1996) 24 Anaesth lntens Care, 66.
21. R. Holland, "Anaesthetic Mortality in New South Wales" (1987) 59 Br J Anaesth, 834. J.C. Warden, C.L. Borton, B.F. Horan, "Mortality Associated with Anaesthesia in NSW, 1984-1990" (1994) 161 Med J Aust 585. J.C. Warden and B.F. Horan, "Deaths Attributed to Anaesthesia in New South Wales, 1984-1990" (1996) 24 Anaesth lntens Care, 66.
22. R. Holland, "Anaesthetic Mortality in New South Wales" (1987) 59 Br J Anaesth, 834. J.C. Warden, C.L. Borton, B.F. Horan, "Mortality Associated with Anaesthesia in NSW, 1984-1990" (1994) 161 Med J Aust 585. J.C. Warden and B.F. Horan, "Deaths Attributed to Anaesthesia in New South Wales, 1984-1990" (1996) 24 Anaesth lntens Care, 66.
23. R.L. Keenan and C.P. Boyan, "Decreasing Frequency of Anaesthetic Cardiac Arrest." (1991) 3 J Clin Anesth 354.
24. C.C.P. Eagle and N.J. Davis, "Report of the Anaesthetic Mortality Committee of Western Australia 1990-1995" (1997) 25 Anaesth Intens Care 51 at 58.
25. J.N. Lunn and H.B. Devlin, "Lessons from the Confidential Enquiry into Perioperative Deaths in Three NHS Regions" (1987) Lancet 1384. Anaesthesia, however, was part of the causative process in producing 1: 1351 deaths per operations. But see: T Pedersen, "Complications and Death Following Anaesthesia- a Prospective Study with Special Reference to the Influence of Patient, Anaesthesia and Surgery -Related Risk Factors" (1994) 41 Danish Medical Bulletin 319; J.B. Forest et al, "Multicenter Study of General Anaesthesia. II. Results" (1990) 72 Anesthesiology 262; G.G. Harrison, "Death Due to Anaesthesia at Groote Schuur Hospital, Cape Town 1956-1987" (1990) 77 South African Medical Journal 416; J.C. Warden, "Morbidity and Mortality Associated with Anaesthesia" (1997) 41 (7) Acta Anaesthesiol Scand 949; A Coetzee, "Mortality Associated with Anaesthesia" (1996) 86 (8) S Afr Med J 973 which reported differing rates.
26. J.N. Lunn and H.B. Devlin, "Lessons from the Confidential Enquiry into Perioperative Deaths in Three NHS Regions" (1987) Lancet 1384. Anaesthesia, however, was part of the causative process in producing 1: 1351 deaths per operations. But see: T Pedersen, "Complications and Death Following Anaesthesia- a Prospective Study with Special Reference to the Influence of Patient, Anaesthesia and Surgery -Related Risk Factors" (1994) 41 Danish Medical Bulletin 319; J.B. Forest et al, "Multicenter Study of General Anaesthesia. II. Results" (1990) 72 Anesthesiology 262; G.G. Harrison, "Death Due to Anaesthesia at Groote Schuur Hospital, Cape Town 1956-1987" (1990) 77 South African Medical Journal 416; J.C. Warden, "Morbidity and Mortality Associated with Anaesthesia" (1997) 41 (7) Acta Anaesthesiol Scand 949; A Coetzee, "Mortality Associated with Anaesthesia" (1996) 86 (8) S Afr Med J 973 which reported differing rates.
27. J.N. Lunn and H.B. Devlin, "Lessons from the Confidential Enquiry into Perioperative Deaths in Three NHS Regions" (1987) Lancet 1384. Anaesthesia, however, was part of the causative process in producing 1: 1351 deaths per operations. But see: T Pedersen, "Complications and Death Following Anaesthesia- a Prospective Study with Special Reference to the Influence of Patient, Anaesthesia and Surgery -Related Risk Factors" (1994) 41 Danish Medical Bulletin 319; J.B. Forest et al, "Multicenter Study of General Anaesthesia. II. Results" (1990) 72 Anesthesiology 262; G.G. Harrison, "Death Due to Anaesthesia at Groote Schuur Hospital, Cape Town 1956-1987" (1990) 77 South African Medical Journal 416; J.C. Warden, "Morbidity and Mortality Associated with Anaesthesia" (1997) 41 (7) Acta Anaesthesiol Scand 949; A Coetzee, "Mortality Associated with Anaesthesia" (1996) 86 (8) S Afr Med J 973 which reported differing rates.
28. J.N. Lunn and H.B. Devlin, "Lessons from the Confidential Enquiry into Perioperative Deaths in Three NHS Regions" (1987) Lancet 1384. Anaesthesia, however, was part of the causative process in producing 1: 1351 deaths per operations. But see: T Pedersen, "Complications and Death Following Anaesthesia- a Prospective Study with Special Reference to the Influence of Patient, Anaesthesia and Surgery -Related Risk Factors" (1994) 41 Danish Medical Bulletin 319; J.B. Forest et al, "Multicenter Study of General Anaesthesia. II. Results" (1990) 72 Anesthesiology 262; G.G. Harrison, "Death Due to Anaesthesia at Groote Schuur Hospital, Cape Town 1956-1987" (1990) 77 South African Medical Journal 416; J.C. Warden, "Morbidity and Mortality Associated with Anaesthesia" (1997) 41 (7) Acta Anaesthesiol Scand 949; A Coetzee, "Mortality Associated with Anaesthesia" (1996) 86 (8) S Afr Med J 973 which reported differing rates.
29. J.N. Lunn and H.B. Devlin, "Lessons from the Confidential Enquiry into Perioperative Deaths in Three NHS Regions" (1987) Lancet 1384. Anaesthesia, however, was part of the causative process in producing 1: 1351 deaths per operations. But see: T Pedersen, "Complications and Death Following Anaesthesia- a Prospective Study with Special Reference to the Influence of Patient, Anaesthesia and Surgery -Related Risk Factors" (1994) 41 Danish Medical Bulletin 319; J.B. Forest et al, "Multicenter Study of General Anaesthesia. II. Results" (1990) 72 Anesthesiology 262; G.G. Harrison, "Death Due to Anaesthesia at Groote Schuur Hospital, Cape Town 1956-1987" (1990) 77 South African Medical Journal 416; J.C. Warden, "Morbidity and Mortality Associated with Anaesthesia" (1997) 41 (7) Acta Anaesthesiol Scand 949; A Coetzee, "Mortality Associated with Anaesthesia" (1996) 86 (8) S Afr Med J 973 which reported differing rates.
30. J.N. Lunn and H.B. Devlin, "Lessons from the Confidential Enquiry into Perioperative Deaths in Three NHS Regions" (1987) Lancet 1384. Anaesthesia, however, was part of the causative process in producing 1: 1351 deaths per operations. But see: T Pedersen, "Complications and Death Following Anaesthesia- a Prospective Study with Special Reference to the Influence of Patient, Anaesthesia and Surgery -Related Risk Factors" (1994) 41 Danish Medical Bulletin 319; J.B. Forest et al, "Multicenter Study of General Anaesthesia. II. Results" (1990) 72 Anesthesiology 262; G.G. Harrison, "Death Due to Anaesthesia at Groote Schuur Hospital, Cape Town 1956-1987" (1990) 77 South African Medical Journal 416; J.C. Warden, "Morbidity and Mortality Associated with Anaesthesia" (1997) 41 (7) Acta Anaesthesiol Scand 949; A Coetzee, "Mortality Associated with Anaesthesia" (1996) 86 (8) S Afr Med J 973 which reported differing rates.
31. Cheney in the ongoing ASA Closed Claims Study has reported a small number of cases in which a pulse oximeter was in use and showed no destauration at the time of unexpected cardiovascular collapse. Cited in R.W .McIntyre, "Symposium Report. Critical Incidents in Anaesthesia. Medico-Legal Consequences" (1991) 38 (8) Can J Anaesth 1035 at 1036. Sato has reported two anaesthetic deaths related to construction work on hospital medical gas pipelines which saw the lines for oxygen and nitrous oxide interchanged. T. Sato "Fatal Pipeline Accidents Spur Japanese Standards" in J.H. Eichhorn (ed), Anaesthesia Patient Safety. A Modern History. Selections from the Anaesthesia Patient Safety Foundation Newsletter (1995) at 240-241.
32. Cheney in the ongoing ASA Closed Claims Study has reported a small number of cases in which a pulse oximeter was in use and showed no destauration at the time of unexpected cardiovascular collapse. Cited in R.W .McIntyre, "Symposium Report. Critical Incidents in Anaesthesia. Medico-Legal Consequences" (1991) 38 (8) Can J Anaesth 1035 at 1036. Sato has reported two anaesthetic deaths related to construction work on hospital medical gas pipelines which saw the lines for oxygen and nitrous oxide interchanged. T. Sato "Fatal Pipeline Accidents Spur Japanese Standards" in J.H. Eichhorn (ed), Anaesthesia Patient Safety. A Modern History. Selections from the Anaesthesia Patient Safety Foundation Newsletter (1995) at 240-241.
33. C.C.P. Eagle and N.J. Davis, "Report of the Anaesthetic Mortality Committee of Western Australia 1990-1995" (1997) 25 Anaesth Intens Care 51 at 58.
34. M. Wilson "Errors and Accidents in Anaesthetics" in C. Vincent, M. Ennis, R.J. Audley (eds), Medical Accidents (1993) 61 at 71.
35. P.W. Thompson, "Safer Design of Anaesthetic Machines" (1987) 59 Br J Anaesthesia 913.
36. A.H. Mayor and J.M. Eaton, "Anaesthetic Machine Checking Practices: A Survey" (1992) 47 Anaesthesia 866. M.G. March and J.J. Crowley, "An Evaluation of Anaesthesiologists' Present Checkout Methods and the Validity of the FDA Checklist" (1991) 75 Anaesthesiology 724.
37. A.H. Mayor and J.M. Eaton, "Anaesthetic Machine Checking Practices: A Survey" (1992) 47 Anaesthesia 866. M.G. March and J.J. Crowley, "An Evaluation of Anaesthesiologists' Present Checkout Methods and the Validity of the FDA Checklist" (1991) 75 Anaesthesiology 724.
38. R. Botney and D.M. Gaba, "Human Factors Issues in Monitoring" in CD Blitt and RL Hines (eds), Monitoring in Anaesthesia and Critical Care Medicine (1995) at 23.
39. J. Firth-Cozens "Stress, Psychological Problems, and Clinical Performance" in C. Vincent, M. Ennis and R.J. Audley (eds), Medical Accidents (1993) at 131.
40. See J.M. Davies, "On-site Risk Management" (1991) 38 (8) Can J Anaesth 1029 at 1030.
41. See A.K. Bacon, "Death on the Table: Some Thoughts on How to Handle an Anaesthetic Related Death" (1989) 44 Anaesthesia 245.
42. J.M. Davies, "Risk Assessment and Risk Management in Anaesthesia" in A.R. Aitkenhead (ed), Baillière's Clinical Anaesthesiology International Practice and Research. Quality Assurance and Risk Management in Anaesthesia (1996) vol 10 (2) at 357.
43. Registration of Births, Deaths and Marriages Act 1973 (NSW) s 24.
44. Ibid s 24(7) (excepting a local anaesthetic administered solely for the purpose of facilitating a procedure for resuscitation from apparent or impending death). See also Coroners Act 1980 (NSW) ss 13 and 14.
45. Coroners Act 1980 (NSW).
46. H. Selby, The Aftermath of Death (1992).
47. C.C.P. Eagle and N.J .Davis, "Report of the Anaesthetic Mortality Committee of Western Australia 1990-1995" (1997) 25 Anaesth Intens Care 51 at 52.
48. Medical Practice Act 1992 (NSW)
49. Health Care Complaints Act 1993 (NSW)
50. A. Dix et al, Law for The Medical Profession in Australia (2nd ed 1996) at 13-17. See G. Furness, "Discipline or Bondage: Aspects of the Disciplinary Jurisdiction Governing Medical Practitioners" (1997) 20 (3) UNSW LJ 760.
51. A. Dix et al, Law for The Medical Profession in Australia (2nd ed 1996) at 13-17. See G. Furness, "Discipline or Bondage: Aspects of the Disciplinary Jurisdiction Governing Medical Practitioners" (1997) 20 (3) UNSW LJ 760.
52. A concept with its origins in The Medical Act 1858 (UK). See Allison v General Council of Medical Education and Registration [1894] 1 QB 750
53. Commonwealth of Australia Department of Human Services and Health, Compensation and Professional Indemnity in Health Care (Interim Report February 1994) at 199-200. A. Dix et al, Law For The Medical Profession in Australia (2nd ed 1996) at 31.
54. Commonwealth of Australia Department of Human Services and Health, Compensation and Professional Indemnity in Health Care (Interim Report February 1994) at 199-200. A. Dix et al, Law For The Medical Profession in Australia (2nd ed 1996) at 31.
55. Exparte Mehan [1965] NSWLR 30
56. Re Anderson and The Medical Practitioners Act; Re Johnson and the Medical Practitioners Act (1967) 85 WN (NSW) 558.
57. Health Act Amendment Act, 1978 (WA) ss 35-36. Health Act, 1911-1978(WA) s. 336B and Part XIIIC.
58. See National Health and Medical Research Council, Report on Anaesthetic Related Mortality in Australia 1985-1987 (1990).
59. Ibid pp.7-8
60. Ie: Health Administration Act 1982 (NSW). Health Services Act 1990 (ACT). Health Insurance (Quality Assurance Confidentiality) Amendment Act 1992 (Cth).
61. NHMRC, Report on Anaesthetic Related Mortality in Australia 1985-1987 (1990). The classification is: I. where it is reasonably certain that death was caused by the anaesthetic agent or technique of administration, or in other ways coming directly within the anaesthetist's province. II. similar cases, but in which there is some element of doubt as to whether the agent or technique was entirely responsible for the fatal result. III. cases in which the patient's death was caused by both the anaesthetic and surgical technique. IV. death entirely referable to the surgical technique. V. inevitable deaths, such as death due to severe general peritonitis, but in which anaesthetic and surgical techniques were apparently satisfactory. VI. fortuitous death, such as death due to pulmonary embolism. VII. death which cannot be assessed despite considerable data. VIII. death on which an opinion could not be formed because of inadequacy of data. Point VI highlights the dated nature of this classification, with pulmonary embolism no longer being regarded as a "fortuitous" as distinct from an eminently preventable event. J.M. Davies, "Anesthetic Risk" in R.D. Miller's Preoperative Preparation and Intraoperative Monitoring (1997) vol III at 2.1-2.7
62. NHMRC, Report on Anaesthetic Related Mortality in Australia 1985-1987 (1990). The classification is: I. where it is reasonably certain that death was caused by the anaesthetic agent or technique of administration, or in other ways coming directly within the anaesthetist's province. II. similar cases, but in which there is some element of doubt as to whether the agent or technique was entirely responsible for the fatal result. III. cases in which the patient's death was caused by both the anaesthetic and surgical technique. IV. death entirely referable to the surgical technique. V. inevitable deaths, such as death due to severe general peritonitis, but in which anaesthetic and surgical techniques were apparently satisfactory. VI. fortuitous death, such as death due to pulmonary embolism. VII. death which cannot be assessed despite considerable data. VIII. death on which an opinion could not be formed because of inadequacy of data. Point VI highlights the dated nature of this classification, with pulmonary embolism no longer being regarded as a "fortuitous" as distinct from an eminently preventable event. J.M. Davies, "Anesthetic Risk" in R.D. Miller's Preoperative Preparation and Intraoperative Monitoring (1997) vol III at 2.1-2.7
63. G. Edwards et al, "Deaths Associated with Anaesthesia. A Report on 1000 Cases." (1956) 11 Anaesthesia, 194.
64. Much interest in this area has been generated in the United States by the similarly entitled Anaesthesia Patient Safety Foundation.
65. See W.B. Runciman et al "Errors, Incidents and Accidents in Anaesthetic Practice" (1993) 21 Anaesth Intens Care, 506.
66. See "Symposium-The Australian Incident Monitoring Study" (1993) 21(5) Journal of the Aust Soc of Anaesthetists. R.K. Webb et al, "The Australian Incident Monitoring Study: An Analysis of 2000 Incident Reports." (1993) 23 Anaesth Intens Care 520. WB Runciman et al, "System Failure: An Analysis of 2000 Incident Reports," (1993) 21 Anaesth Intens Care 684. J.A. Williamson et al, "Human Failure: An Analysis of 2000 Incident Reports." (1993) 21 Anaesth Intens Care, 678.
67. See "Symposium-The Australian Incident Monitoring Study" (1993) 21(5) Journal of the Aust Soc of Anaesthetists. R.K. Webb et al, "The Australian Incident Monitoring Study: An Analysis of 2000 Incident Reports." (1993) 23 Anaesth Intens Care 520. WB Runciman et al, "System Failure: An Analysis of 2000 Incident Reports," (1993) 21 Anaesth Intens Care 684. J.A. Williamson et al, "Human Failure: An Analysis of 2000 Incident Reports." (1993) 21 Anaesth Intens Care, 678.
68. See "Symposium-The Australian Incident Monitoring Study" (1993) 21(5) Journal of the Aust Soc of Anaesthetists. R.K. Webb et al, "The Australian Incident Monitoring Study: An Analysis of 2000 Incident Reports." (1993) 23 Anaesth Intens Care 520. WB Runciman et al, "System Failure: An Analysis of 2000 Incident Reports," (1993) 21 Anaesth Intens Care 684. J.A. Williamson et al, "Human Failure: An Analysis of 2000 Incident Reports." (1993) 21 Anaesth Intens Care, 678.
69. See "Symposium-The Australian Incident Monitoring Study" (1993) 21(5) Journal of the Aust Soc of Anaesthetists. R.K. Webb et al, "The Australian Incident Monitoring Study: An Analysis of 2000 Incident Reports." (1993) 23 Anaesth Intens Care 520. WB Runciman et al, "System Failure: An Analysis of 2000 Incident Reports," (1993) 21 Anaesth Intens Care 684. J.A. Williamson et al, "Human Failure: An Analysis of 2000 Incident Reports." (1993) 21 Anaesth Intens Care, 678.
70. E.A. Campling et al, The Report of the National Confidential Enquiry into Perioperative Deaths (1990).
71. J.B. Cooper et al, "Preventable Anaesthesia Mishaps: A Study of Human Factors" (1978) 49 Anaesthesiology 399. J.B. Cooper et al, "An Analysis of Major Errors and Equipment Failures in Anaesthesia Management: Considerations for Prevention and Detection" (1984) 60 Anaesthesiology, 34.
72. J.B. Cooper et al, "Preventable Anaesthesia Mishaps: A Study of Human Factors" (1978) 49 Anaesthesiology 399. J.B. Cooper et al, "An Analysis of Major Errors and Equipment Failures in Anaesthesia Management: Considerations for Prevention and Detection" (1984) 60 Anaesthesiology, 34.
73. Ibid.
74. The Report of the Harvard Medical Practice Study to the State of New York (1990).
75. See J.H. Eichhorn, J.B. Cooper, D.J. Cullen et al, "Standards for Patient Monitoring During Anaesthesia at Harvard Medical School" (1986) 256 JAMA, 1017.
76. J.H. Eichhorn "Historical Perspective" in JH Eichhorn (ed), Anaesthesia Patient Safety. A Modern History. Selections from the Anaesthesia Patient Safety Foundation Newsletter (1995) at 2.
77. Its "mission" was stated as being to "assure that no patient shall be harmed by the effects of anaesthesia." Its purposes being to "foster investigations that will provide a better understanding of preventable anaesthetic injuries; encourage programs that will reduce the number of anaesthetic injuries; and promote national and international communication of information and ideas about the causes and prevention of anaesthetic morbidity and mortality." E.S. Siker, "Editorial: Historical Perspective of APSF Shows Safety Advocacy" (1996) Fall APSF Newsletter, 26.
78. Contactable via Dr J.B. Cooper, e-mail: cooper@etherdome.mgh.harvard.edu The second meeting of ICPAMM in Vienna in September 1986, involved 62 participants from 19 countries.
79. http://www.medana.unibas.ch/ENG/CIRS/Cirs.htm
80. J.B. Cooper, "ICPAMM Meeting Review of Safety Includes New Worldwide Expansion" (1996) Fall APSF Newsletter 1. The next meeting of ICPAMM will be at the European Congress of Anaesthesiologists in Frankfurt in 1998.
81. J. Craig and M.E. Wilson, "A Survey of Anaesthetic Misadventures" (1981) 36 Anaesthesia, 933.
82. W.P.S. McKay and W.H. Noble, "Critical Incidents Detected by Pulse Oximetry During Anaesthesia" (1988) 35 Canadian Journal of Anaesthesia, 265.
83. M. Currie, "A Prospective Study of Anaesthetic Critical Events in a Teaching Hospital" (1989) 17 Anaesthesia and Intensive Care, 403.
84. D.C .Galletly and N.N. Mushet, "Mortality Associated with Anaesthesia. A Case Review Study" (1991) 19 Anaesthesia, 66.
85. V. Chopra et al, "Reported Significant Observations During Anaesthesia: A Prospective Analysis over an 18-Month Period" (1992) 68 Br J of Anaesthesia, 13.
86. Ibid at 34-35.
87. Waikato Hospital, New Zealand, Death in Operating Theatre: Procedure to Be Followed (20 February 1996).
88. J.N. Armstrong and J.M. Davies, "A Systematic Method for the Investigation of Anaesthetic Incidents" (1991) 38 (8) Can J Anaesth, 1033.
89. A.R. Aitkenhead, "Anaesthesia" in J.P. Jackson (ed), A Practical Guide to Medicine and the Law (1991) at 45.
90. R.A.Caplan et al, "Adverse Respiratory Events in Anaesthesia: A Closed Claims Analysis" (1990) 72 Anaesthesiology, 828.
91. G. Taylor, C.P. Larson, R. Prestwich, "Unexpected Cardiac Arrest During Anaesthesia and Surgery. An Environmental Study." (1976) 236 JAMA, 2758.
92. R.A. Caplan et al, "Adverse Respiratory Events in Anaesthesia; A Closed Claims Analysis" (1990) 72 Anaesthesiology, 828.
93. K. Gannon, "Mortality Associated with Anaesthesia. A Case Review Study" (1991) 46 Anaesthesia 962. See also J.E. Utting, T.C. Gray and F.C. Shelley, "Human Misadventure in Anaesthesia" (1979) 26 Can Anaesth Soc J, 472.
94. K. Gannon, "Mortality Associated with Anaesthesia. A Case Review Study" (1991) 46 Anaesthesia 962. See also J.E. Utting, T.C. Gray and F.C. Shelley, "Human Misadventure in Anaesthesia" (1979) 26 Can Anaesth Soc J, 472.
95. J.M. Davies and R. Robson, "The View from North America and Some Comments on "Down Under'" (1994) 73 Br J Anaesthesia, 105 at 113.
96. E.A. Campling et al, The Report of the National Confidential Enquiry into Perioperative Deaths 1990 (1992).
97. R v Yosasakaran [1990] 1 NZLR 399.
98. 71 Long v R [1995] 2 NZLR 691.
99. Long v R [1995] 2 NZLR 691 at 700.
100. R v McDonald High Court, Christchurch, T 24/82, 24 October 1982, Roper J.
101. R v Yogasakaran [1990] 1 NZLR 399.
102. R v Morrison High Court, Dunedin, S 7/91, 23 April 994, Fraser J.
103. Sir Duncan McMullin, Report to Hon Douglas Graham, Minister of Justice, on Sections 155 and 156 of the Crimes Act 1961 (1995) at 41.
104. Ibid at 42.
105. Ibid at 40.
106. Ibid at 41.
107. R v Adomko[1993] 4 Med LR 304.
108. D. Brahams, "Two Locum Anaesthetists Convicted of Manslaughter" (1990) 45 Anaesthesia 981. (1990) 336 Lancet, 430.
109. D. Brahams, "Two Locum Anaesthetists Convicted of Manslaughter" (1990) 45 Anaesthesia 981. (1990) 336 Lancet, 430.
110. R v Sargent (1990) 336 Lancet. 430.
111. J.M Davies and R. Robson "The View from North America and Some Comments on "Down Under"" (1994) 73 British Journal of Anaesthesia, 105 at 114.
112. R v Giardine (1939) 71 CCC, 295.
113. F.W. Cheney, "Anaesthesia and the Law; the North American Experience." (1987) 59 British Journal of Anaesthesia 891. Sec also G.J. Annas "Medicine, Death and the Criminal Law" (1995) 333 N Engl J Med, 527.
114. F.W. Cheney, "Anaesthesia and the Law; the North American Experience." (1987) 59 British Journal of Anaesthesia 891. Sec also G.J. Annas "Medicine, Death and the Criminal Law" (1995) 333 N Engl J Med, 527.
115. Ibid 528 citing In the Matter of Joseph J. Verbrugge. MD, Colorado Board of Examiners, No. ME 93-06 (May 17, 1994).
116. Ibid.
117. R v Gunter [1921] 21 SR (NSVV) 282
118. Callaghan v R [1952] 87 CLR 115 and Griffiths v R [1994] 69 CLR 77.
119. See M. Milde, "Aircraft Accident Investigation in International Law" (1984) 9 (1) Air Law, 61.
120. Ibid at 62.
121. Ibid at 64.
122. Ibid.
123. L Barron, "Aircraft Accident Investigation-Whose Interest Prevails?" (1984) 8 (2) Air Law, 87.
124. See A.A. vanWijk, "Criminal Liability of Pilots Following an Airline Accident; a History of the Issue Within the International Federation of Air Line Pilots Associations (IFALPA)" (1984) 9(1) Air Law 66 at 70. R Dettling-Ott, "Criminal Liability of Airline Pilots: Three Recent Decisions" (1988) 8 (1) Air Law 4.
125. See A.A. vanWijk, "Criminal Liability of Pilots Following an Airline Accident; a History of the Issue Within the International Federation of Air Line Pilots Associations (IFALPA)" (1984) 9(1) Air Law 66 at 70. R Dettling-Ott, "Criminal Liability of Airline Pilots: Three Recent Decisions" (1988) 8 (1) Air Law 4.
126. See R.I.R. Abeyratne, "Negligence of the Aircraft Commander and Bad Airmanship-New Frontiers" (1987) 7 (1) Air Law 3. NM Matte, The International Legal Status of the Aircraft Commander (1975). P Martin, "Death and Injury in International Air Transport" (1975) 41 Journal of Air Law and Commerce, 255.
127. See R.I.R. Abeyratne, "Negligence of the Aircraft Commander and Bad Airmanship-New Frontiers" (1987) 7 (1) Air Law 3. NM Matte, The International Legal Status of the Aircraft Commander (1975). P Martin, "Death and Injury in International Air Transport" (1975) 41 Journal of Air Law and Commerce, 255.
128. See R.I.R. Abeyratne, "Negligence of the Aircraft Commander and Bad Airmanship-New Frontiers" (1987) 7 (1) Air Law 3. NM Matte, The International Legal Status of the Aircraft Commander (1975). P Martin, "Death and Injury in International Air Transport" (1975) 41 Journal of Air Law and Commerce, 255.
129. See L. Barron, "Aircraft Accident Investigation-Whose Interest Prevails?" (1984) 8 (2) Air Law 87 at 92.
130. D.M. Gaba and A. DeAnda, "A Comprehensive Anaesthesia Simulation Environment: Re-Creating the Operating Room for Research and Training." (1988) 69 Anaesthesiology 387. A. DeAnda and D.M. Gaba, "Unplanned Incidents During Comprehensive Anaesthesia Simulation" (1991) 72 Anaesthesia and Analgesia 77. H.A. Schwid and D. O'Donnell, "Anaesthesiologist's Management of Simulated Critical Incidents" (1992) 76 Anaesthesiology 495. J.M. Davies, "Simulation: It's a Start" (1996) 43 (5) Can J Anaesth, 425.
131. D.M. Gaba and A. DeAnda, "A Comprehensive Anaesthesia Simulation Environment: Re-Creating the Operating Room for Research and Training." (1988) 69 Anaesthesiology 387. A. DeAnda and D.M. Gaba, "Unplanned Incidents During Comprehensive Anaesthesia Simulation" (1991) 72 Anaesthesia and Analgesia 77. H.A. Schwid and D. O'Donnell, "Anaesthesiologist's Management of Simulated Critical Incidents" (1992) 76 Anaesthesiology 495. J.M. Davies, "Simulation: It's a Start" (1996) 43 (5) Can J Anaesth, 425.
132. D.M. Gaba and A. DeAnda, "A Comprehensive Anaesthesia Simulation Environment: Re-Creating the Operating Room for Research and Training." (1988) 69 Anaesthesiology 387. A. DeAnda and D.M. Gaba, "Unplanned Incidents During Comprehensive Anaesthesia Simulation" (1991) 72 Anaesthesia and Analgesia 77. H.A. Schwid and D. O'Donnell, "Anaesthesiologist's Management of Simulated Critical Incidents" (1992) 76 Anaesthesiology 495. J.M. Davies, "Simulation: It's a Start" (1996) 43 (5) Can J Anaesth, 425.
133. D.M. Gaba and A. DeAnda, "A Comprehensive Anaesthesia Simulation Environment: Re-Creating the Operating Room for Research and Training." (1988) 69 Anaesthesiology 387. A. DeAnda and D.M. Gaba, "Unplanned Incidents During Comprehensive Anaesthesia Simulation" (1991) 72 Anaesthesia and Analgesia 77. H.A. Schwid and D. O'Donnell, "Anaesthesiologist's Management of Simulated Critical Incidents" (1992) 76 Anaesthesiology 495. J.M. Davies, "Simulation: It's a Start" (1996) 43 (5) Can J Anaesth, 425.
134. J.N. Armstrong and J.M. Davies, "A Systematic Method for the Investigation of Anaesthetic Accidents" (1991) 38 Can J Anaesth, 1033.
135. J.M. Eaton and M.E. Wilson, Anaesthesia Action Plans (1991).
136. D.M. Gaba et al, "Anaesthesia Crisis Resource Management Training" (1991) 75 Anaesthesiology A1062.
137. F.H. Hawkins, Human Factors in Flight (1987).
138. J.N. Armstrong and J.M. Davies, "A Systematic Method for the Investigation of Anaesthetic Incidents" (1991) 38 (8) Can J Anaesth, 1033 at 1035.
139. Such as the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) arising from the Final Act Embodying the Results of the Uruguay Round of Multilateral Trade Negotiations. See: P. Drahos, "Global Property Rights in Information: The Story of TRIPS at GATT" (1995) 13 Prometheus 6. PLC Torremans, "Compulsory Licensing of Pharmaceutical Products" (1996) 27 Int. Rev. of Ind. Property and Copyright Law 316.
140. Such as the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) arising from the Final Act Embodying the Results of the Uruguay Round of Multilateral Trade Negotiations. See: P. Drahos, "Global Property Rights in Information: The Story of TRIPS at GATT" (1995) 13 Prometheus 6. PLC Torremans, "Compulsory Licensing of Pharmaceutical Products" (1996) 27 Int. Rev. of Ind. Property and Copyright Law 316.
141. B.M. Knoppers and R. Chadwick, "The Human Genome Project: Under An International Ethical Microscope" (1995) 46 (2) Int Digest of Health Legislation 263. The UNECSO Draft declaration on the Human Genome, for example, provides that it is the "common heritage of humanity" (articlel). This "soft law" statement is possibly designed to "metamorphose" into "hard law" once, for example, patent rights begin to restrict patient access to genetic based medical therapies. "TRIPS also lays firmly to rest the idea that technology is the common heritage of mankind and replaces it with the idea that technology is the heritage of the heirs of intellectual property owners." P. Drahos, "Thinking Strategically About Intellectual Property Rights" (1997) 21(3) Telecommunications Policy 201 at 205.
142. B.M. Knoppers and R. Chadwick, "The Human Genome Project: Under An International Ethical Microscope" (1995) 46 (2) Int Digest of Health Legislation 263. The UNECSO Draft declaration on the Human Genome, for example, provides that it is the "common heritage of humanity" (articlel). This "soft law" statement is possibly designed to "metamorphose" into "hard law" once, for example, patent rights begin to restrict patient access to genetic based medical therapies. "TRIPS also lays firmly to rest the idea that technology is the common heritage of mankind and replaces it with the idea that technology is the heritage of the heirs of intellectual property owners." P. Drahos, "Thinking Strategically About Intellectual Property Rights" (1997) 21(3) Telecommunications Policy 201 at 205.
143. Ibid.
144. In the US, the Center for Study of Responsive Law has already done much work on the nexus between intellectual property and health care. Ibid at 207.
145. World Medical Association, Declaration of Geneva, as amended at Sydney, 1968. See also World Medical Association, International Code of Medical Ethics: "A doctor must always bear in mind the obligation of preserving human life."
146. World Medical Association, Declaration of Geneva, as amended at Sydney, 1968. See also World Medical Association, International Code of Medical Ethics: "A doctor must always bear in mind the obligation of preserving human life."