THE HISTORY OF ANAESTHETIC MORTALITY REPORTING
Is mortality reporting nearing the end?
D G Fenwick
Royal Adelaide Hospital, Adelaide, SA
The history of anaesthetic mortality reporting is intimately bound up with the office of the coroner. The earliest records of the formal office of the coroner appear in England in the 12th century. The coroner served as the king’s local agent. The function of the coroner in the 16th century was described as ensuring the receipt of royal revenues through the administration of justice. Part of the administration included the investigation of violent death, which was deemed to be detrimental to the royal revenue.
Science, particularly medicine, was in an age of questioning and progress during the 19th century. Some notable achievements were: the theory and benefits of inoculation, the importance of epidemiology and the vindication of the “germ theory” of disease. It is no wonder that anaesthesia arose during this time. Arguably, anaesthesia is the greatest advancement in medical care to benefit humans in recent times. The benefit is not only for anaesthesia itself, which is priceless, but also for the permissive effect it has given to medicine, particularly in areas such as surgery, radiology, cardiology and gastroenterology, resulting in their advancement.
The anaesthesia timeline:
- Ether was first used and accepted in 1846.
- Chloroform was first used in 1847.
The coroner’s timeline:
- The first coronial inquest into death under anaesthesia was held in 1848.
This was held into the death of Hanna Greener, under chloroform anaesthesia by the coroner of Newcastle upon Tyne. Over the next decades, debate ensued as to the legal status of the patient. Patients were said to have lost their will and rights, which now rested with the anaesthetist. Anaesthetists were not allowed to restrain patients unwilling to have an anaesthetic, but were allowed to restrain patients in the second stage of anaesthesia. Gradually the anaesthetist became responsible for the patient’s welfare. By 1904 it had become law that all deaths under anaesthetic had to be reported to the coroner and that an anaesthetist may not sign a death certificate. This is the only category of reportable death due to medical care. This situation persists to-day.
The medical response to deaths under anaesthesia, not the coroner’s constraints, was to collect statistics and the reasons for the deaths were explored. The Royal Medical and Chirurgical Society Committee, which was one of many bodies, medical and lay, looking into the deaths, reported in 1864 that chloroform lowered the blood pressure. It recommended that monitoring during chloroform anaesthesia should be via the pulse. This was backed up by the Glasgow Committee in 1878.
However, it was reported that between 1879 and 1889 chloroform had been administered with uniform safety using Syme’s method of watching the respiration.
The Nizam of Hyderabad, who was interested in the topic, agreed to fund an enquiry into the causes of death under chloroform anaesthesia. Two Commissions were held, one in 1888 and the other in 1889, and were named the Hyderabad Commissions in honour of the Nizam. The findings were reported back to the Nizam by Dr Edward Laurie, the Colonial Resident Doctor. The findings were wildly wrong, but demonstrated a commitment to patient safety and avoiding problems.
The findings:
- A fall in blood pressure is never dangerous.
- The action of the heart is not weakened.
- A sudden fall in blood pressure is due to activity in the vagus nerve.
- Neither the pulse nor the respiration furnish timely warnings of approaching danger to the heart.
Given this state of medical knowledge, mortality reporting was a valuable tool in progressing the debate on safety in anaesthesia. As medical knowledge increased, so the complexity of anaesthesia increased and mortality reporting remained a valuable tool.
Gilbert Brown instituted an individual record for each patient having an anaesthetic. He was thus able to collect and analyse the deaths under anaesthesia at the Royal Adelaide Hospital from 1932 to 1936. He drew many important conclusions on improving patient safety and disseminated them through the newly formed Australian Society of Anaesthetists. Geoffrey Kay, writing in the British Journal of Anaesthesia, describes this as Gilbert Brown’s finest achievement in a brilliant career. Even up to late last century, which is but a few years ago, lessons from deaths were learned and broadcast, for example the adequacy of pre-anaesthetic work up and the administration of sedation.
At present, mortality reporting still has to occur to the coroner. We should be part of that, collect the data, analyse them and disseminate lessons learned, even though deaths in association with anaesthesia are now infrequent in our system.
In many parts of the world, anaesthesia is still primitive, and mortality analysis and reporting has an important part to play in teaching patient safety.
Time of Presentation
Sunday 14 May 2006 - 1330-1500
References
1. Bodies of Evidence: Medicine and the Politics of the English Inquisition, 1830-1926. Ian A Burney. Baltimore, Johns Hopkins. ISBN 0-8018-6240-X.
2. Dr Edward Lawrie’s Remarks on the Findings of the Hyderabad Chloroform Commissions in His Annual Report of 1303 Fasli.
3. Bull. Ind. Hist. Med. Vol XXVI pp 93-102.
4. Anaesthetic Fatalities. Gilbert Brown.
5. Royal Adelaide Hospital Reports, No 30, 1950.
