The publication of an Inquest at the Coroner’s Court in South Australia makes disturbing reading:  the inquest investigated the deaths of 2 patients and highlighted significant concerns regarding admission and post-operative practices for high-risk surgical patients undergoing surgery in small private hospitals.

A particular concern was the inadequate preoperative “flagging” of high-risk patients, such that anaesthetists involved in their care were ignorant of pertinent clinical issues until first meeting their patients, shortly before surgery was due to commence.  As the Coroner commented:

“Despite the predictable anaesthetic challenges which both Mr R. and Mrs W. posed, neither had the benefit of a pre-anaesthetic consult. In Mr R’s case, the surgeon did not think of arranging it. In Mrs W’s case, it was overlooked because of a system failure in the surgeon’s rooms. As a consequence, the respective anaesthetists had to deal with the situation under pressure, moments before surgery.”


Although there are many other recommendations in the report, it is clear that anaesthetists are being presented with high-risk patients immediately before surgery, with minimal opportunity to properly assess and manage peri-operative strategies.  If the anaesthetists had been adequately pre-warned, it is highly likely that the unfortunate deaths could have been avoided.

Patient history, investigations and clinical warnings are an essential part of pre-warning anaesthetists of difficult, high-risk patients.  See how VaperTrail handles these critical elements of information.