Mr.

Akamodo’s case

Mr. Akamodo’s right eye had been bothering him for some time. His vision was blurry and at
times he had a prickling sensation in the eyes. Mr Akamodo had also noticed the sudden
appearance of many floaters — tiny specks that seem to drift through his field of vision. After
consultation with the eye doctor Mr Akamodo was scheduled for eye surgery of a detached
retina in his right eye. The eye operation was carried out at the Juneday Hospital, Gildford on
4 January 1997.

The operation was carried out by two surgeons supported by a team of five nurses and a
theatre sister. Anaesthesia commenced at about 9.45 a.m. Mr Akamodo was paralysed by
injection of a drug and an endotracheal tube was inserted to enable him to breathe by
mechanical means. At the start of the operation the anaesthetist was Dr. Sayd, a registrar. An
operating department assistant was also present to help him.

The endotracheal tube which was providing Mr. Akamodo with oxygen was connected at one
end to the supply, went under the drapes of the patient and into the patient’s mouth. At some
time after Dr. Anderson took over responsibility for his patient and the tube became detached
from the connector point.

At about 10.30 a.m. there was a changeover of anaesthetists. Dr. Anderson was called to
attend and take Dr. Sayd's place following which both Dr. Sayd and his assistant departed to
deal with another operation elsewhere in the hospital. Another assistant was called to attend
but did not arrive until later.

At approximately 11.05 a.m. a disconnection occurred at the endotracheal tube connection.

The supply of oxygen to the patient ceased and this led to cardiac arrest at 11.14 a.m. It
appears that during this period Dr. Anderson failed to notice or remedy the disconnection.

Dr. Anderson first became aware that something was amiss when an alarm sounded on the
Dinamap machine, which monitors the patient's blood pressure. From the evidence it
appears that some 4½ minutes would have elapsed between the disconnection and the
sounding of this alarm. When this alarm sounded Dr. Anderson responded in various ways by
checking the equipment and by administering atropine to raise the patient's pulse. But at no
stage before the cardiac arrest did he check the integrity of the endotracheal tube
connection.

One of the nurses did notice a few strange things during the operation but said nothing at the
time. For example, she noticed that at some point the patient’s chest was not moving, that
the dials on the mechanical ventilating machine were not operating and that, strangely, the
alarm in the ventilating machine had not gone off (which is set to do so if the machine
malfunctions). She was about to signal this to Dr. Anderson when the alarm on the Dinamap
machine went off. She also noticed that the patient’s pulse and blood pressure had dropped
but thought that Dr. Anderson was aware of this. The disconnection in the endotracheal tube
was not discovered until after resuscitation measures had been commenced.

Professor Payne is a doctor and a professor at the University of Chesfield. He has vast
experience in anaesthetics. According to Professor Payne, during these types of surgeries
doctors are expected to pay special attention to any signs that the patient is not breathing, or
has difficulty doing so. Standard signs of ward emergency include, patient bleeding or other
excretion of other body fluids, rapid chest movements, slow or imperceptible chest
movement, changes in skin colour, sweating, slow pulse and low blood pressure and,
evidently, any machine disconnections or machine alarms going off. Doctors are expected to
recognise these signs and to react accordingly within 15 seconds after noticing any sign of
patient distress.

On the other hand Dr. Monks, also a professor at the University of Guildford, has said that
although Dr. Anderson ought to have noticed the disconnection, there are factors which
mitigated this failure. Dr. Monks considers that another independent problem either occurred
or could have occurred before or at the same time as the disconnection which distracted Dr.
Anderson's attention and activities. This problem would in his view have caused the patient's
blood pressure to drop and may either have been a reaction to the drug being used to
paralyse the patient or alternatively may have been caused by an ocular cardiac reflex.

Dr. Anderson himself has said that when the alarm sounded on the Dinamap machine his
first thought was that the machine itself was not working properly. Having carried out checks
on the machine he then thought that the patient had suffered an ocular cardiac reflex for
which he administered atropine in two successive doses. Further attempts to administer
atropine by intravenous drip and to check the patient's blood pressure followed until the
cardiac arrest occurred. It had never occurred to him that a disconnection had taken place.
He has stated that ''after things went wrong I think I did panic a bit… I did not think anything
was wrong with the patient. Only after the alarm went off did I notice a few strange things in
the patient, so I reacted accordingly and followed the standard ward-emergency protocols for
patient care".

In relation to Dr. Anderson's actions during this period Professor Payne has said that "given
that Dr. Adomako misled himself, the efforts he made were not unreasonable". The period
Professor Payne refers to is obviously the period after the alarm had sounded on the
Dinamap machine which was as I have said apparently some 4½ minutes after the
disconnection occurred.