A coroner has raised concerns about the administration and prescription of anaesthetic after a woman died following a hip replacement in which she was given an “excessive” dose of anaesthetic.

Philip Barlow, the Assistant Coroner for the coroner area of Cambridgeshire and Peterborough, has produced a Prevention of Future Deaths Report following the death of Dr Rachel Gibson.

Dr Rachel Gibson was 47 when she underwent a hip replacement at Spire Lea Hospital in Cambridge in April 2022. She had suffered from severe osteoarthritis prior to the surgery.

Towards the end of the procedure she was given a local anaesthetic, Ropivacaine, which was used in “excess of the recommended dose”, the report found.

Following the surgery, Dr Gibson suffered an unwitnessed cardiac arrest. She was resuscitated and transferred to Addenbrooke’s Hospital where she was found to have sustained irreversible brain damage, a coroner found.

She died at Addenbrooke’s Hospital on July 14, 2022.

The coroner said: “The evidence was that it is routine practice before the procedure for the anaesthetist to give oral instructions to the scrub nurse specifying the type and dose of local anaesthetic to be used to infiltrate the operation site.

“Towards the end of the operation the scrub nurse hands the local anaesthetic to the surgeon who then carries out the infiltration.

“The intention in this case was for a 2% solution of Ropivacaine to be diluted 50/50 with normal saline before it was infiltrated.

“The evidence suggested that this was not done. The result was that excessive Ropivacaine was administered by mistake.”

The coroner identified several matters of concern in the report, which was sent to the Royal College of Anaesthetists.

The matters of concern were: “The responsibility for checking and administering the local anaesthetic is unclear:

“The instruction was given orally and not written down by the anaesthetist (the
prescriber).

“The anaesthetist did not check what the nurse had written down.

“The nurse drew up the local anaesthetic from a stock bag and checked this with
another nurse, but not with the anaesthetist.

“The nurse then handed the drawn-up anaesthetic to the surgeon to administer.

“There is inconsistency in the way the local anaesthetic was prescribed. The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams.

“This is of particular concern when the intention is for the drug to be diluted. If the drug is always prescribed in milligrams then the scope for error may be reduced.

“The hospital in question has now introduced a system for labelling and countersigning the drug that is being given during the operation.

“However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation.”

The Royal College of Anaesthetists has a duty to respond to the report within 56 days of the date, which will be October 29, 2024.

Dr Gibson was a cancer scientist. She had previously completed her PhD in neuroendocrinology at Downing College in Cambridge.

She was described as a “wonderful mum” and an “amazing wife” by her widower, Cliff Gibson.

He told the Press Association: “She loved her career, the industry she worked in and trusted in the medical system and those in it more than anyone.

“She went into her operation with the clear belief that it would be a success and she would be able to regain her mobility and enjoy living her life again.”