A 41-year-old project manager, Mrs F, underwent breast uplift surgery, performed on a private basis.
Induction of anaesthesia was performed by Dr T using propofol and fentanyl, and a laryngeal mask airway was inserted. A muscle relaxant was also administered. Anaesthesia was maintained with a propofol infusion, and a remifentanil infusion was also used.
Shortly after Mrs F had been transferred from the anaesthetic room to theatre, it was noted her heart rate significantly increased, as did her blood pressure. Although this change was recorded on the anaesthetic monitoring printout, it was not recorded in the handwritten anaesthetic chart.
Dr T noted the changes and considered the increase in heart rate and blood pressure indicated the level of anaesthesia was light, and so the rate of infusion of both propofol and remifentanil were increased, and midazolam was also given.
Dr T did not record on the anaesthetic chart why these measures had been taken.
The surgery proceeded uneventfully, but on recovering from anaesthesia Mrs F stated to ward staff that she had “woken up” during the operation and could hear the surgeon talking and feel tugging and pushing. She tried to scream and move away, but could not.
She later brought a claim against Dr T for intraoperative accidental awareness resulting in psychiatric injury.