Selection for surgery 3 - model answer

Design a consent form specifically for laparoscopy, listing the main risks (both general and
specific) of laparoscopic surgery.

Model answer

You should consider how to express in plain English the risks listed below. When counselling
patients for surgery it is imperative that you use appropriate language and check
understanding.

General risks of anaesthesia and surgery:

 venous thromboembolism
 atelectasis leading to infection
 MI or CVA
 death

Procedure specific risks:

 haemorrhage resulting in transfusion, re-operation, prolonged stay in hospital

 damage to other organs, resulting in further surgery and a longer recovery time
 the insufflation gas may give pain and other complications
 infection secondary to collections requiring reoperation and or drainage with prolonged
hospitalisation
 adhesions formation resulting in bowel complications, further surgery and prolonged
hospitalisation
 keloid scar formation
 hernia formation at the wound site
 in obese patients and smokers, more wound and chest infection, heart and lung
complications and VTE
 fistula formation
 symptoms for which the procedure is being done, e.g. pain may be no better after the
operation
 there may be no cause for the problem found at surgery

You may wish to refresh your knowledge of the GMC guidelines on consent:

General Medical Council. Consent: patients and doctors

making decisions together. GMC. 2008.
Selection for surgery 4 - model answer
Consider what you might need to do to set up a laparoscopy service in a hospital where this
does not already exist. Consider this task and discuss your thoughts with your educational
supervisor, using the article below for guidance. Use this exercise to help complete your
management modules in your portfolio.

Monkhouse S, Burgess P. Setting up a new service. BMJ Careers 2009.

Model answer

In order to perform laparoscopic surgery appropriately, the level of expertise of the surgeon is
critical, as is support from other surgical disciplines. For most procedures, experienced
assistance is needed and becomes increasingly important as the complexity of surgery
increases.

Many surgical centres in Europe and increasingly in the UK have more than one advanced
laparoscopic surgeons, who will operate together for exactly this reason. Experienced
anaesthetic support is equally important in understanding the unique effects of a
pneumoperitoneum on respiratory and cardiac function as well as an appreciation of the
particular operative challenges the surgeon faces.

Finally, the theatre set-up is also vital in terms of staff and equipment. Without experienced
theatre staff that are familiar with the range of equipment and instruments required during
laparoscopy, safe surgery is impossible.

You only have to have experienced the difficulties associated with performing an emergency
laparoscopy outside normal hours with unfamiliar staff to appreciate how important this is. It
is the operating surgeon's responsibility to be familiar with all equipment or instruments that
they intend to use.

Theatre setup 1 - model answer

Write short notes on how you would set up the patient for a diagnostic laparoscopy.

Model answer

Your answer should discuss positioning the patient on the table:

1. Patient positioning is crucial to successful surgery and this is particularly true during
laparoscopic surgery. It is good practice for the operating surgeon to supervise positioning of
the patient prior to scrubbing. A non-slip mat is essential for all procedures
2. If the patient is too high up the table, full anteversion of the uterus will not be possible,
compromising the operative view of the pelvis. Conversely, if positioned too low, the patient is
at risk of musculoskeletal injury due to inadequate support of the lower back and sacrum
3. Ideally, specially designed lithotomy stirrups should be used to support the patient's
legs. As well as providing padded support for the legs, the position can be adjusted by the
surgeon during surgery. This is especially useful for combined hysteroscopic and laparoscopic
surgery, or for laparoscopic assisted vaginal hysterectomy
4. If conventional poles with stirrups are used, gel padding should be placed between the
leg and pole to avoid peripheral nerve injuries
5. The lower back should be well supported with the buttocks just over the end of the
table
6. The patient's arms need to be secured away from the operating field and allow
anaesthetic access to peripheral cannulae
7. Remember that the entire abdomen, from xiphisternum to pubis, constitutes the
potential operating field and needs to be available to the surgeon. Changing the position of
arms or drapes during surgery causes unnecessary delay as well as potentially contaminating
the surgical site
8. For prolonged laparoscopic procedures, warming blankets or 'bear-huggers' should be
used as well as thromboembolic deterrent stockings
9. Contrary to popular belief, routine bladder catheterisation is not required for the
majority of patients undergoing laparoscopy

This practice stems from the original practice of suprapubic placement of the Veress needle
for insufflation, which risked bladder injury. The first sensation to void is typically 200 ml and
is likely to be lower in a nervous pre-operative patient.

The bladder needs to contain in excess of 250 ml to extend above the pubic symphisis and this
can easily be excluded during the routine bimanual examination that is performed at the start
of each case. Postoperative urinary retention is associated with extensive dissection,
prolonged procedures and postoperative pain.

In view of this, indwelling catheters are recommended for patients undergoing complex
surgery.

Theatre setup 2 - model answer

With the increasing problem of obesity in our population, how would you alter your preparation
and management for a patient with morbid obesity who is to undergo laparoscopic surgery?

Model answer

Your answer should include preoperative preparations standard to any obese patient.
Additional considerations include the equipment requirements, e.g. operating table limitations,
longer trocars and Veress needles, surgical and assistant expertise. Finally you should
consider the postoperative recovery time and how this patient will be managed.

Consider:

Should you encounter a complication such as bowel injury, what back up would be available
from your general surgical team? Should this operation include their input?

ning › Teaching-materials › Surgical Procedures and Postoperative Care

› Minimal access surgery - Teaching Resource

 Case studies
 Tasks
o Selection for surgery 1
o Selection for surgery 1 - model answer
o Selection for surgery 2
o Selection for surgery 3
o Selection for surgery 3 - model answer
o Selection for surgery 4
o Selection for surgery 4 - model answer
o Theatre setup 1
o Theatre setup 1 - model answer
o Theatre setup 2
o Theatre setup 2 - model answer
o Entry techniques 1
o Entry techniques 1 - model answer
o Entry techniques 2 - model answer
o Entry techniques 2
o Entry techniques 3
o Entry techniques 3 - model answer
o Secondary ports
o Secondary ports - model answer
o Monopolar and bipolar current
o Monopolar and bipolar current - model answer
 Short answer question

Entry techniques 1 - model answer

Read the article below:

Ahmad G, Duffy JMN, Phillips K, Watson A. Laparoscopic entry

techniques. Cochrane Database Syst Rev 2008;(1):CD006583.

Now write short notes on each of the following:

1. classic entry point

2. direct insertion
3. Hassan technique
4. modified classic entry

Model answer: Classic entry

Most surgeons employ what we will call the classic approach. An incision is made below the
umbilicus, the abdominal wall is grasped firmly and a Veress needle is passed at 45°. Once its
position is felt to be correct, 2–3 litres of gas is insufflated and the primary trocar inserted at
45°.

Most complications follow this method; hence, alternatives have been developed. The
argument, "I have always done it this way and not had problems" is untenable, as only the
statistics of low complication rates protect these surgeons, not their skills.

Model answer: Direct insertion

The direct insertion technique avoids the use of the Veress needle altogether. The primary
torcar is thrust through all layers sub-umbilically, with the gas tap open so as to allow air to
enter freely on puncturing the peritoneum, and encourage the bowel to fall away.

This is a very rapid technique that will avoid any complications related to the use of the
Veress needle. It will not, however, avoid primary trocar injury.

In Jansen's study, for instance, only five major complications from 70 607 laparoscopies were
attributed to Veress needle, as opposed to 68 due to trocar injury. Soderstrom's study looked
retrospectively at 47 reported cases of major vessel injury resulting in successful litigation.
Such injuries were seven-times more likely to happen with a trocar.

It is worth remembering that in these studies, trocar injuries happened following insufflation –
the overall injury rate may, therefore, be even higher with direct entry.

Whatever the incidence, the treatment for a Veress needle bowel injury can usually be
managed conservatively with careful observation in hospital and antibiotics. Laparotomy is
mandatory for a trocar puncture. The bowel is most likely to be damaged when it becomes
adherent beneath the umbilical entry site.

In this situation, a direct insertion technique would risk an unrecognised 'through-and-through'

perforation and, as such, this method cannot be commended for patients at risk of such
adhesions.

A through-and-through injury.

The view through the laparoscope would be normal and give no indication of this perforation.
It is, therefore, necessary with this technique at completion of the procedure to withdraw the
laparoscope under direct vision to detect any through-and-through injury.

Further reading

Jansen FW, Kolkman W, Bakkum EA, de Kroon CD, Trimbos-Kemper TC,

Trimbos JB. Complications of laparoscopy: an inquiry about closed-
versus open-entry technique. Am J Obstet Gynecol 2004;190:634–8
[Abstract].
Soderstrom RM. Injuries to major blood vessels during endoscopy. J
Am Assoc Gynecol Laparosc 1997;4:395–8 [Abstract].

Model answer: Open laparoscopy

The open technique described in 1971 by Hasson is gaining popularity, especially among
general surgeons. Basically, this is an intra-umbilical mini-laparotomy with a sealed cannula.
The peritoneal cavity is entered bluntly under direct vision.

Further reading

The risk of bowel damage after closed laparoscopy in the three most tightly controlled trials is
0.3 in 1000, and after open laparoscopy in the three best studies it is 0.4 in 1000. Even with
the large sample sizes, this is not significant.

The data do provide two conclusions:

 open laparoscopy does succeed in virtually eliminating type I injuries to the bowel and
major vessels
 it does not eliminate the risk of type II bowel damage. Possibly, this is because the method does
not allow recognition of bowel adhesions prior to direct cut down. There are, however, various
manoeuvres by which the Veress needle can be used to detect bowel adhesions, thus allowing a
different entry site to be chosen, thereby avoiding serious danger. In such a situation, a closed Veress
needle technique may have advantages over open entry

Jansen FW, Kolkman W, Bakkum EA, de Kroon CD, Trimbos-Kemper TC,

Trimbos JB. Complications of laparoscopy: an inquiry about closed-
versus open-entry technique. Am J Obstet Gynecol 2004;190:634–8
[Abstract].
Soderstrom RM. Injuries to major blood vessels during endoscopy. J
Am Assoc Gynecol Laparosc 1997;4:395–8 [Abstract].

Model answer: Modified classic approach

A modified classic closed entry technique incorporates safety measures designed to minimise
all recognised complications.

This is based on the skin incision, the Veress insertion, the elevation of the abdominal wall,
insufflation to a pressure higher than that used for operating to splint the abdominal wall, and
once insufflation has occurred, correct positioning for trocar insertion.

Entry techniques 2 - model answer

Name two tests that you can perform to assess whether your Veress needle is correctly
positioned.
Describe how you would perform the tests.

Model answer

Your answer should include:

1. Palmers test
2. Insufflation test

Palmers test

A 10 ml syringe filled with normal saline is attached to the Veress needle. Aspiration is then
performed and absence of bowel content or blood suggests these structures have been
avoided.

Saline is then flushed through the cannula and there should be no resistance to flow.
Aspiration is then repeated and should only result in capture of saline if the tip of the needle is
within adhesions and the fluid has collected in a loculation.

Finally, as the syringe is disconnected the fluid level within the needle should be seen to drop
due to negative pressure in the peritoneal cavity.

Insufflation test

A high CO2 flow rate and low intra-abdominal pressure indicate correct placement as gas is
flowing freely into the peritoneal cavity. In practice, if the initial insufflation pressure is less
than 10 mmHg then the needle tip is invariably in the correct place.
The flow rate should approximate that noted at the initial test of the Veress needle function.
High pressures with a low flow rate suggests an incorrect position and the needle should be
withdrawn carefully without lateral movement.

Entry techniques 3 - model answer

Look at the table below, and consider what you would estimate the risk of peri-umbilical
adhesions to be in each case.

Model answer

Group Previous surgery Umbilical adhesions (%)

1 None 0.38
2 Major operative laparoscopy 0.71
3 Laparotomy – lower transverse 6.89
incision
4 Laparotomy – midline incision 31.25
This information suggests that almost one-third of patients with previous surgery through a
midline incision will be at risk from the primary trocar if it is inserted at the umbilical site. In
over half of these patients, the adhesions involved the bowel. In cases such as these,
therefore, an alternative primary entry site should be considered.

Secondary ports - model answer

List the risks associated with secondary ports and describe how you would manage these.

Model answer

The most common complication during secondary trocar insertion is injury to vessels of the
anterior abdominal wall:

Superficial vessels

Superficial circumflex iliac artery – a branch of the femoral artery passing below the inguinal
laigment then laterally towards the anterior superior iliac spine.

Superficial epigastric artery – also a branch of the femoral artery, crosses over the inguinal
ligament and is distributed towards the umbilicus.

Deep vessels

Inferior epigastric artery and vein – a branch of the external iliac artery medial to the deep
inguinal ring, passing superiorly behind the conjoint tendon to enter the rectus sheath behind
the muscle. A popular landmark is the obliterated umbilical artery or medial umbilical ford,
which passes medially to the inferior epigastric artery.

The position for secondary ports must, of course, be appropriately chosen to best facilitate
the particular operation being carried out, but also be safely away from important vessels. The
principal structure to be avoided is the inferior epigastric artery.

It is a popular misconception that this can be reliably identified by transillumination. It can,

however, be seen laparoscopically arising from the deep inguinal ring at the origin of the round
ligament, and ascending with its two venae commitantes lateral to the obliterated umbilical
artery.
For most procedures, the secondary trocars can be effectively and safely placed lateral to this position.
Superficial vessels of the anterior abdominal wall can often be shown by transillumination and avoided
in this way.

Key fact
It is an important basic principle of laparoscopic safety
that all secondary ports should be inserted and withdrawn
under direct vision.

Monopolar and bipolar current - model answer

Have you had formal training in the use of diathermy? If not ensure that you obtain it.

List the differences between monopolar and bipolar diathermy in terms of how the current is
poroduced, transmitted and the effect on surrounding tissues.

Model answer

Electrosurgical energy is commonly used in two ways. Monopolar current, generated by an

electrosurgical unit (ESU) flows from the tip of the active electrode, usually a needle, scissors
or graspers, through the patient, and grounds to the patient's return electrode.

As the active electrode is small, there is a high current density and tissue effects occur
through heating. The return electrode has an area of approximately 150 cm 2 and, hence, very
low current density, so there is very little tissue heating.

Tissue damage may extend far from the point of contact and the extent of the damage is
related to the form of energy used. With monopolar current, energy preferentially dissipates
via vascular pathways. Although only a small serosal burn is evident, there may be a much
larger area of underlying devascularisation.

Bipolar electrosurgery involves using an instrument incorporating both an active and passive
electrode, usually some form of grasping forceps. Current flows only through the tissue held
between the paddles and there is consequently little surrounding necrosis.

The tissue between the instrument paddles does, however, become very hot, and power should
be only activated for the minimum time necessary to reduce risks from the thermal spread.

Watch the following videos of bipolar and monopolar diathermy. It is important that all
surgeons are familiar with the properties of energy sources. Operator error in relation to
electrosurgical equipment is more commonly responsible for bowel trauma than equipment
failure.

Complications of electrosurgery - model answer

Write a short essay on the how potential diathermy complications arise during laparoscopic
surgery and how you would aim to minimise the risk of this occuring.

Model answer

Answers should include the following:

Insulation failure
Consider the fact that 90% of the instrument is out of the surgeon's view. The characteristics
of electrical energy are such that unobserved damage may be occurring away from the active
tip.

All instruments must be regularly inspected for the integrity of the insulated shaft and, if the
desired effect is not evident, diathermy should be ceased immediately rather than blindly
calling for power to be increased. The surgeon's view shows no effect at the point of tissue
contact with the jaws of the forceps.

An unobserved bowel injury occurs as current grounds through a break in the insulation.

Direct coupling

It can be easy to unintentionally heat tissue close to the target. Imagine a loop of bowel very
close to a bleeding vessel. Its very proximity puts it at risk of damage as the vessel is
coagulated, especially if monopolar current is used.

As tissue is further diathermied, it becomes desiccated and its impedance, or resistance to

current flow, increases. If diathermy continues, power may flow preferentially to adjacent non-
desiccated tissue by arcing, and cause damage in this way.

Again, this is most likely where monopolar current is used, as the voltages required are high.

Conducted thermal burn

Any tissue that has become hot through diathermy should be allowed to cool before it comes
into contact with bowel. An example would be needle diathermy to polycystic ovaries, where
they retain heat for a considerable time and can cause a thermal burn to the bowel if allowed
to rest back in proximity.

Cooling can be facilitated by irrigation with saline via a suction or wash device.

Capacitance coupling

A detailed understanding of electrophysics is not necessary, but awareness that there is

another mechanism by which diathermy instruments can cause severe electrical burns is
important. The energy delivered by the ESU to your instrument can be partially coupled, or
transferred, to the trocar cannula.

If this cannula is all-plastic it will not ground, but if it is all-metal it will allow current to
dissipate harmlessly over a wide area to the abdominal wall. The problem occurs with the
part-metal part-plastic cannulae, which will not dissipate the current away and may allow it to
ground in a high density fashion to the patient, causing a burn.

Capacitance coupling causing a burn (encircled).

A second mechanism, which risks injury, occurs when the instruments are brought close
together within the peritoneal cavity. Current can transfer from the active electrode to, for
example, the telescope.

If the telescope lies within an all-metal cannula, then the current again dissipates harmlessly
to the abdominal wall. If a plastic cannula is used, however, it may ground in a high-density
fashion to bowel or other pelvic contents, causing a thermal burn.

Salpingotomy - model answer

A 26-year-old G0P0 woman presents with seven weeks of amenorrheoa with a previous normal
cycle and a positive pregnancy test.
 She has had very light vaginal spotting for 24 hours. Ultrasonography shows an empty uterus
and a complex mass in the right adnexae with a fetal heart beat noted.

Outline your management.

Model answer

1. Diagnosis suggesting high suspicion of ectopic pregnancy

2. Counsel patient on probable diagnosis, management and outcome and future fertility
3. Treatment options including medical (methotrexate) and surgical
4. Surgical options should include both laparoscopy and potential laparotomy, including
complications of surgery, anaesthetic and general complications
5. The merits and disadvantages of salpingostomy versus salpingectomy
6. Future contraception options, need for care with future pregnancy and early
investigation to establish the presence of a future intrauterine pregnancy
7. Need for 'safe sex', and risks of infection on future fertility, the possibility of recurrent
ectopic and the need to plan pregnancy

Do not include:

 History and reasons for diagnosis

 Serial βHCG
 Further ultrasound scans
 Conservative (i.e. observational) management
Ovarian cystectomy - model answer
You have just opened the abdomen to perform a routine hysterectomy for fibroids in a 37-year-
old woman. She was not consented for oophorectomy.

You note that one ovary is about 10 cm in diameter with an irregular outline, with mixed cystic
and solid components. There is ascites in the abdominal cavity.

Describe your actions and the reasons for them.

Model answer

1. Diagnosis with a mixed cystic and solid mass has a high index of suspicion for
malignancy
2. Frozen section can be done prior to proceeding if this is available and ascites sampling
taken from the abdomen
3. Proceed to total hysterectomy and bilateral salpingooophorectomy and omentectomy
with palpation of the abdomen, peritoneum, liver and para-aortic nodes. This should ideally be
with the advice and discussion with the gynae-oncology team
4. Postoperatively, the patient needs debriefing on the findings and the resulting decision
to proceed and the operation that has been performed
5. The patient needs advice on the need for histological diagnosis and told the likely
timescale involved
6. If the histology is malignant, gynae-oncology referral is required. Arrange imaging and
biochemistry and tumour markers.
7. If the histology is benign no further treatment is required and she should be
commenced on HRT with the advice to use this to the age of about 50

Do not include:

 History and investigation with biochemistry, imaging or tumour markers as these are
not relevant in this case
 Avoiding oophorectomy in the absence of consent, or discussions on future fertility is
incorrect management
 Risk identification - model answer
Think about possible means of risk identification in terms of internal and external sources.

Model answer

Internal sources:

 risk assessment conducted in all clinical areas

 incident reporting
 complaints and claims
 staff consultation – workshops, surveys and interview
 clinical audit

External sources:

 National Confidential Enquiries

 CNST Maternity Standards
 RCOG guidelines, protocols and visitations
 Postgraduate Dean's visit
 Care Quality Commission reports
 Ombudsman Reports
 Task 4 - model answer
List six situations where you consider it to be prudent to share information about sexual
activity?

Model answer

 where you think the young person is too immature to understand

 there has been force or threat, coercion, bribery or payment either to the activity or to
keep it secret
 where there is a big difference in age, maturity or power between sexual partners,
where the young person is below the age of consent or their sexual partner is in a position of
trust
 where drugs or alcohol were used to influence the young person to engage in sexual
activity
 where the person involved is known to the police or child protection agencies as having
abusive relationships with children or young people
 you would usually share information about sexual activity involving children under 13
years who are considered in law to be unable to consent. (In Scotland it is under the age of 12,
although the Courts take a particularly serious view if unlawful sexual intercourse has taken
place with a girl under 13 years of age)
 all Trusts in England will have a named Child Protection Lead/Nurse who should be
contacted if you have any concerns. They will be fully aware of the processes that need to be
followed and may find it easier to access the appropriate agencies that need to be involved.

A flowchart that can be used to guide clinicians when they are in doubt about how to deal with
young people who are sexually active can be found here: NHS Tayside Child Protection Policy,
2006.

Informed Consent - Model Answer

Mrs Prudence Brown is a 48 year old Afro-Caribbean woman from St. Kitts. Mrs Brown has a
long history of heavy vaginal bleeding despite medical treatment and the Levonorgestrel
intrauterine system.

Her recent Haemoglobin level was 8.1g/dL. Haematinics have confirmed iron-deficiency
anaemia.

Clinically Mrs Brown appears pale and a multifibroid uterus is palpated just above the
umbilicus.

Endometrial sampling shows no hyperplasia, atypia or malignancy.

After a long discussion, a hysterectomy is decided upon as the best course of action.

However, Mrs Brown mentions she is a Jehovah’s Witness and is adamant she would not
accept a blood transfusion under any circumstances.

Model Answer

The following should be taken in to consideration with this case study:

1. Capacity needs to be fully assessed. If the patient is found to have capacity, her
autonomy must be respected
2. It would be viewed as assault to give a blood transfusion to a Jehovah’s Witness if they
have declined it
3. For the consent to be valid, the patient must be competent to make the decision, have
received sufficient information to make the decision and not be acting under duress
4. In this case, the patient must be made aware of and able to discuss the risks/benefits
of the transfusion and the consequences of not having the transfusion
5. She must receive appropriate written information.
Informed consent for under 16's case study - Model Answer
Kelly O’Sullivan is seen by a doctor with a long experience in family planning. Kelly is 15 years
old and is requesting the oral contraceptive pill (OCP). Kelly is sexually active and has been in
a relationship with her boyfriend for 3 months. She does not wish to become pregnant. The
Doctor discusses safe sex and barrier contraception, but after the consultation the doctor felt
that Kelly was acting responsibly and therefore prescribed the pill. The doctor did encourage
Kelly to discuss the situation with her family, but Kelly did not feel comfortable to do so.
 Six weeks later, Kelly’s mother found a strip of the OCP in Kelly’s handbag. After confronting
Kelly and not obtaining any information, the mother came to clinic demanding to see the
doctor who prescribed the pill to her “under age” daughter. She questioned the morality and
competence of the doctor involved. She also wanted to know why her husband and she had not
been informed and their permission sought.

Model Answer

The following issues should be taken in to consideration with this case study:

1. Confidentiality – the doctor cannot disclose information, i.e. break confidentiality, to

Kelly’s mother (Data Protection Act).
2. Fraser Guidelines 1985 – it is not illegal to prescribe contraception to patients under 16
years of age as long as they comprehend the consequences and risks.
Death certification
Mrs Jane Brown was a 26-year-old woman at 37 weeks in her second pregnancy who has just
died in your labour suite after six hours of active resuscitation. Her first pregnancy was an
emergency caesarean section for fetal distress two years ago. Earlier in the day she
underwent an elective section. She was suspected of having a low-lying anterior placenta and
at the section it was discovered that she had a placenta percreta. Despite all efforts, including
30 units of blood and blood products, interventional radiology and a caesarean hysterectomy,
she finally bled to death. She was never stable enough to be transferred to the intensive care
unit in the main hospital.

How would you fill out a death certificate for Mrs Brown?

Click here to open a blank form.

In order to complete the death certificate, you will need the information below. Use your own
name and qualifications, but the hospital address shown.

 Date of death: 10 June 2006

 Time of death: 6pm
 Place of death: Abersheen Maternity Hospital
 Consultant: Dr McPherson

Your address: C/O The Maternity Unit, Abersheen Maternity Hospital, Abersheen AB3 5WW.
Contacting the authorities about a death - model answer
List five circumstances where you would contact the authorities about a death.

Model answer: Deaths reportable to the Coroner (England and Wales)

 A death should be referred to HM Coroner if there are any suspicious circumstances –
violence, accident or neglect. This should also include sudden or unexpected deaths of which
the cause is unknown and, specifically, deaths due to:

 abortion or miscarriage
 accidents of any kind, however long before death they occurred
 acute alcoholic poisoning
 anaesthetic deaths
 drugs, even when used therapeutically
 industrial disease (a full list can be found in the certificate book)
 medical mishaps/errors (death caused by an operative error/mishap must always be
reported). The death of a seriously ill person after a properly performed operation that was
part of the treatment must also be reported. Complaints by the bereaved would make it wise
to request postmortem examination via the Coroners Office
 the death of a person in receipt of a war or industrial pension
 poisoning of any kind
 death of prisoners or anyone in custody
 death occurring during or shortly after detention in police or prison custody
 stillbirths if there is any doubt whether the child was born alive
 the deceased was detained under the Mental Health Act
 any local hospital admission/discharge rule

Deaths reportable to the Procurator Fiscal (Scotland)

The Procurator will enquire into any sudden, suspicious, accidental, unexpected and
unexplained death. He or she may enquire into any death brought to his or her notice if it is
thought necessary to do so, especially where the evidence or circumstances suggest that the
death may fall into one or more of the following:

 death due to violent, suspicious or unexplained cause

 death involving fault or neglect on the part of another
 possible or suspected suicide
 death arising out of the use of a vehicle, including an aircraft, ship or train
 death by drowning
 any death by burning or scalding, or as a result of a fire or explosion
 certain deaths of children – death of a newborn child whose body is found, sudden
death in infancy, death due to suffocation, including overlaying, death of a foster child
 death at work, whether or not as a result of an accident
 death related to occupation; for example, industrial disease or poisoning
 death as a result of abortion or attempted abortion
 death as a result of medical mishap and death where a complaint is received which
suggests that medical treatment or the absence of treatment may have contributed to the
death
 death due to poisoning, including by prescription or non-prescription drugs, other
substances, gas or solvent fumes
 death due to a notifiable infectious disease, or food poisoning
 death in legal custody
 death of a person of residence unknown, who died other than in a house
 death where a doctor has been unable to certify a cause

If you are in any doubt at all, lift the phone and discuss it either with the Coroner or the
Procurator Fiscal. Remember that the Procurator Fiscal will always be a lawyer; if the Coroner
is not a doctor, you will need to explain in terms that should be understandable to them.
 Abortion Case Study - Model Answer
Faaiso Ali is 31 years old and is in her second pregnancy. She booked late at 17 weeks and
since then has been in Somalia. Faaiso is seen when she returns at 28 weeks pregnant. All
booking bloods are normal.

However, a detailed ultrasound scan has revealed the baby has anencephaly, which is
incompatible with extrauterine life. She is referred to the fetal medicine team who have
confirmed the diagnosis and prognosis.

She is very shocked by the findings and feels unable to make a decision about termination of
the pregnancy until she has discussed with her family. The idea of termination is not
completely rejected, however Faaiso does not want to regret her decision.

Model Answer

1. Termination of pregnancy (TOP) is covered by the Abortion Act (1991) and under clause
E TOP is possible at any stage of pregnancy if the fetal condition is incompatible with
extrauterine life
2. TOP should ideally be performed as soon as possible
3. Feticide would be required in this case as the pregnancy is more than 22 weeks
gestation
4. The patient and family (if the patient wishes) need to be fully counselled and time
given for all questions
5. If the patient decides against TOP routine antenatal care must continue.
HIV
A woman who is HIV positive is five months pregnant. She has not told her new partner that
she has HIV and does not want him to know. She claims that she is not having sex with him or
the father of the baby anymore.

She is on antiretroviral therapy and at delivery the baby will be due to receive the same. She is
not prepared to tell her partner of her status, despite all efforts by her obstetrician. She says
that she will make sure that the baby gets his therapy after the delivery. The consultant
paediatrician takes it upon himself to inform the partner without the woman's consent about
her status and without talking to her, because he believes that the partners' lack of
information will compromise the treatment for the baby.

What are your views of this situation?