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Fire in airway during laser surgery (04HDC04340)
Download Fire in airway during laser surgery (04HDC04340) (PDF 158Kb)
(04HDC04340, 19 May
Anaesthetist ~ Surgeon ~ Public hospital ~ District health
board ~ Stenosis ~ Laser surgery ~ Airway fire ~ ACC ~
Documentation ~ Vicarious liability ~ Rights 4(1), 4(2), 6(1)(b),
A woman had required a number of procedures since birth to treat
a severe narrowing of her airway. The surgeon managing her care
recommended laser surgery to treat the stenosis. The woman insisted
that she not have a tracheostomy performed, although it was the
surgeon's and anaesthetist's first choice, and it was agreed to
proceed, in the hope that a laser-proof endotracheal tube of a
sufficiently small size could be used.
After the woman was anaesthetised, it was found that the
stenosis was more severe than assessed at the preoperative clinic,
and that the smallest size of laser-proof endotracheal tube
available was too large to be used. Consequently, a non-laser-proof
tube was introduced and the decision was made to continue with the
procedure without waking the woman and informing her. A surgical
registrar performed the procedure under the surgeon's supervision.
The woman had not consented to the involvement of the registrar in
During the procedure an airway fire occurred, resulting in full
thickness mucosal burns to the subglottis, glottis, and laryngeal
surface of the epiglottis with minor burns to the tracheal mucosa,
mucosa of the main bronchi and the oropharynx. In addition, the
endotracheal tube melted in the fire, with 2cm of the distal end
falling into the bronchus, beyond reach of the equipment available.
A further attempt to retrieve the lost portion of tube failed. The
following day the woman gave her consent to a tracheostomy to
recover the lost portion of tube. This attempt was successful, and
the woman was eventually discharged.
ACC found "medical error" on the part of both the surgeon and
It was held that the surgeon breached Rights 6(1)(b) and 7(1) as
he failed to fully inform the woman of the risk of airway fire
associated with the procedure. The surgeon did not document the
registrar's involvement, breaching Right 4(2) by failing to keep
adequate records, and he breached Right 6(1)(d), as the woman was
not informed of the registrar's involvement.
Both the surgeon and the anaesthetist failed to document their
preoperative discussions, breaching Right 4(2). They both breached
Right 4(1) by proceeding with the surgery in the presence of an
escalating level of risk.
The public hospital was found not vicariously liable for the
surgeon's and the anaesthetist's breaches of the Code.