The background
Mrs Fuller was to have a spinal anaesthetic for the caesarean birth of her second child. The registrar had initially attempted insertion of the introducer (larger needle) and the spinal needle (smaller needle) at the level of L4/5 and then L3/4. He was unsuccessful several times and hit bone or ligamentous material each time (his evidence in relation to the exact number of times he attempted the insertion of the needles was unclear, but the Court found that he made 2 attempts at L3/4 and 1 attempt at L4/5), which led to the consultant then attempting to insert the needles.
When the consultant attempted to insert the needles at L4/5, she hit also bone but was able to insert the needle to its full depth. She then checked if the needle was properly positioned by checking whether cerebrospinal fluid could be drawn back into the needle. It could not and so she concluded that the needles were in the incorrect position. She pulled out both needles at which time it was noticed that half the spinal needle was not present. She advised the patient that half the spinal needle was lodged in her back. It was then surgically removed by a neurosurgeon from level L4/5.
Between each attempted insertion by the registrar and the consultant, the needles were placed on a sterile surface and there was no apparent damage to them.
Findings
In considering whether the registrar and consultant were negligent, the Court determined that the risk that a spinal needle may break and cause an injury was reasonably foreseeable (in the sense that it was not far-fetched or fanciful). Although a very rare event, the available medical literature directed to this occurrence documented it.
The Court held that the most likely explanation for the broken needle was that the consultant hit bone or hard ligamentous material when inserting the spinal needle and thereby bent or deformed the needle.
The proposed precaution to minimise the risk of needle breakage was to discard the spinal needle after unsuccessful attempts to administer the anaesthetic and recommence the procedure using a fresh spinal needle. The issue for determination was whether an anaesthetist (with the attributed characteristics) would have taken the precaution of changing the needle in the circumstances.
In expert conclave, evidence was given that a reasonably competent anaesthetist in the position of the consultant ought to have known of the risk that the spinal needle could break. However, the experts indicated that competent practice would not require the replacement of a spinal needle after 2 or 3 attempts at insertion. Despite no formal consensus being reached between the experts, the Court considered that based on the thrust of the expert conclave, changing the spinal needle after about 7 attempts at insertion was consistent with competent practice. On this basis, the Court held that the medical practitioners’ conduct was not in breach of the duty of care owed to Mrs Fuller.
The Court emphasised that this finding was on the background of the materialisation of a rare or very rare risk (that is, the spinal needle breaking).
To read the decision in Fuller v Australian Capital Territory [2022] ACTSC 361, click here.
