A Perth GP has been referred to Ahpra over the death of a toddler after morphine was used to sedate the child during a circumcision procedure.
Dr Raad Hassan carried out the procedure on two-year-old David Flynn and his younger brother Joseph at his Gosnells clinic in December 2021.
The boys were sent home with their mother after the procedure, but David was later found unresponsive and taken to Armadale Kelmscott Memorial Hospital by ambulance, before being pronounced dead that night.
Joseph also suffered damage to his frenular artery during the circumcision and had to be transferred to Perth Children’s Hospital to undergo emergency surgery to control bleeding on the same night.
A coronial inquest into the death has revealed several critical lessons for doctors performing procedures with sedation, particularly in a general practice setting.
Coroner Robyn Hartley found that the cause of David death was cardiorespiratory arrest due to opioid (morphine) toxicity and the inquest concluded his death was preventable had the appropriate guidelines been followed.
While the general consensus from expert witnesses was that circumcisions can be performed in a general practice setting, there were numerous clinical and procedural failings that ultimately contributed to David’s death.
Failure to monitor
“The critical issue in David’s case arose out of the administration of sedation in the form of morphine,” Coroner Hartley found.
“Procedural sedation, particularly in children, comes with significant known risks. These risks can be mitigated if the sedationist complies with requirements aimed at ensuring patient safety.”
The Coroner noted that the most critical failure was around monitoring and discharge.
David was discharged while still deeply sedated less than an hour and a half after receiving morphine, before the drug’s peak effect.
“Given that the peak effect for subcutaneous dosing of morphine is expected at 50 to 90 minutes post injection and the effects of morphine can last up to three to four hours, it is hard to comprehend the fact that David was discharged from the clinic less than an hour and a half after he was administered the drug,” the coroner found.
The Australian and New Zealand College of Anaesthetists’ Guideline, which is endorsed by the RACGP, mandates continuous monitoring of oxygen saturation, heart rate, and respiration rate during the procedure and recovery.
It outlines that a patient should only be discharged when they are easily arousable, their cardiovascular function is stable, and they have met their pre-procedure neurological baseline. None of these were observed in David’s case, the coroner found.
Expert evidence confirmed that had David been appropriately monitored at the clinic, his deterioration could have been identified and his life likely saved.
Procedural failures
Dr Hassan’s decision to provide a 30mg dose of morphine through a 1mL hollow bore needle increased the likeliness of inaccuracy in dosing. While the dosage amount was not considered unusual given the toddler’s weight of 16kgs, the type of needle used was called into question.
Dr Tanya Farrell, a Perth anaesthetist who gave expert evidence at the inquest, said the use of morphine, the needle that was used and the way it was administrated all posed problems.
“Dr Farrell pointed to the fact that the type of syringe that Dr Hassan used has a dead space in the needle containing a volume you can’t reliably predict. So that when you push the plunger down to empty you will always have a small amount of unmeasurable fluid left behind, eroding the accuracy of the dosing,” according to the coroners report.
Other failings were also noted by the coroner, including a failure to review a medical report and inform the family of pre-procedure protocols.
Dr Hassan was found to have failed to review an ultrasound report that indicated David had undescended testicles, a condition that would typically warrant a referral to a paediatric surgeon.
An expert witness confirmed that if David had needed surgery the circumcision could have been performed safely while he was under general anaesthesia.
David’s family had also not been instructed that he should fast before the procedure and had therefore given him a meal prior to the circumcision
While this was not found to be a direct cause of death, the failure to observe fasting protocols was deemed a “significant error” as sedated patients have diminished protective reflexes and morphine is an emetic.
Final conclusions
In handing down her findings Coroner Hartley said procedural sedation in children comes with significant known risks that can be mitigated with requirements aimed at ensuring safety.
“Of particular relevance in this instance, is the need to ensure the setting in which the procedure occurs is appropriately staffed, equipped and set up, the patient is monitored peri and post-operatively and discharge criteria are strictly adhered to,” she said.
She said she was “acutely aware” of the busy environments general practitioners work in and that while Dr Hassan had failed in his professional duty to ensure David’s safety, he had done so “inadvertently”.
“To honour David’s memory we must ensure that the lessons learnt from his death are shared and acted upon in the hope that no other family has to endure a loss like the one the Flynn’s must live with.”
The full coroner’s report can be read here.
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