Family calls for urgent review of how anaesthetic is administered following death of mother

4th Sep 2024

• Dr Rachel Gibson, 47, died after a toxic amount of anaesthetic was wrongly administered during routine hip replacement surgery.

• Coroner issues Prevention of Future Deaths Report to Royal College of Anaesthetists (RCOA) to identify where improvements can be made.

• Inquest revealed ‘inconsistency’ and ambiguity in the way anaesthetics are administered at hospitals nationally.

Dr Rachel Gibson, 47, died after a toxic amount of anaesthetic was wrongly administered during routine hip replacement surgery.

The devastated family of a loving mother who died after mistakes were made in her care are calling for an urgent national review of the ‘inconsistent’ way in which anaesthetic is delivered to patients.

Rachel Gibson suffered a cardiac arrest following hip replacement surgery at Spire Lea Hospital in Cambridge on 12 April 2022.

The 47-year-old mother, an accomplished cancer scientist, sustained irreversible brain damage and died at Addenbrooke’s Hospital three months later.

At the Inquest into her death, the Coroner raised concerns about the variations in processes adopted nationally in prescribing, checking and administering anaesthetics for the type of procedure Rachel underwent.

On Friday 30^th August he issued a Prevention of Future Deaths Report to the Royal College of Anaesthetists (RCAO) to examine existing practices and see if improvements can be made after it was revealed that similar practices to that which occurred in Rachel’s operation are used nationally.

Evidence revealed during the Inquest revealed that the specific drug given to Rachel was sometimes specified in millilitres whilst on other occasions measured in milligrams.

In Rachel’s case a 2% solution of Ropivacaine, a local anaesthetic, should have been diluted with saline before it was infiltrated. Evidence heard during the Inquest suggested this was not done and an excessive amount of the drug was wrongly administered.

Rachel was an accomplished cancer scientist and completed her BSc in Anatomy and Human Biology, with first class honours at Kings College London followed by a PhD in Neuroendocrinology at Downing College, University of Cambridge.

 Cliff Gibson, 49, husband of Rachel, said:

“Rachel was a loving daughter, a wonderful mum to Sam, an amazing wife and a loyal friend to so many people, Rachel’s ethos was to always do the right thing – and to always do it right. Her passion, drive and ambition was, and will always be, an inspiration.

“In her profession, Rachel cared about the process and doing everything right for her patients at all times. 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.

 “It was devastating for us as a family to learn that there is a fundamental problem with inconsistencies and ambiguities in the way anaesthetics are given to patients across the country. We now know that there are major problems with basic record keeping, training, handover notes and communication.

 “Now that the Coroner has issued a Prevention of Future Deaths Report we have to trust that the RCOA, the body responsible for safeguarding standards in anaesthesia, will prioritise an investigation to ensure that a new and consistent national framework is adopted to avoid anyone else going through what we have experienced as a family.

 “Major changes need to be made and we will do everything we can to ensure that happens so that appalling mistakes like this never happen again.

“Rachel’s personality was quirky and beautiful, always smiling, always thinking of others. While experiencing so much pain prior to the operation in April 2022 she still ensured she was there for her family, friends and colleagues, despite in private often being reduced to tears with the pain she was in.

“Rachel dedicated so much of her time to our autistic son, Sam, now aged 13, who still to this day struggles to talk about his mum and does not understand how she went in for what he was told was a simple operation and never came home.”

Amber Braybrooke at HCC.

Amber Braybrooke, partner at HCC, which represented the family during the Inquest, added:

“Following a thorough Inquest led by the Coroner, we now have answers in terms of what went wrong leading to the tragic death of Rachel. We now wait patiently for the RCOA to respond formally to the Prevention of Future Deaths Report issued by the Coroner.

“This will give us the opportunity to examine precisely what changes need to be immediately implemented not only to improve patient safety, but to ensure such a similar loss of life is not repeated. We accept that it has been acknowledged that there is an inconsistent system across the country and hope that this case raises awareness and sees mandatory systematic change.”

(Cliff, Rachel and Sam – photography provided by family).