AC-2024-MAN-000469 - [2025] EWHC 2049 (Admin)

The Appellant described his actions with respect to Patient A to the Tribunal as follows:

“So when you have a patient who is thrashing their head around violently from side to side and you are trying to maintain a face mask on the patient, which is something that anaesthetists do as a subcon...Through our training and our experience we are hard-wired to reflexively keep masks on patients. Now, not only are we keeping - trying to keep the mask in place so we can deliver oxygen and the anaesthetic, we’re also, in the process of doing that, we are exerting a level of restraint in order to keep the mask on. Now, in this particular instance, over a very short period of time, my hands were variously ... my hands were variously moving continuously to try to reseat the mask of the patient and they were also moving in space in order to restrain and maintain the mask…

So whilst I’m effectively wrestling with the patient’s airway and bearing in mind this is happening over a very short space of time and things are happening simultaneously I look up and I also see that the patient’s arms and legs are flailing around, and at the speed of a, you know, at the speed of thought, I immediately thought, “Holy moly, this guy is gonna fall off the table any second now”. So I shouted out to the theatre staff who were busy about their activities around the operating theatre, to come and help, which they did, including Cara Baker from her position at the computer on the other side, so they came to prevent the patient falling off the table. I immediately said to Kathryn Singh, “You need to put a cannula in quickly”, which she tried and failed. Cara Baker’s standing there seeing that Kathryn Singh had failed, grabbed a cannula off the anaesthetic machine and put one in, through which the remainder of the drugs were given, and the patient the situation was retrieved…

Bearing in mind I’m still wrestling with a morbidly obese patient who’s thrashing around while all this is going on. This is not casual observation, this is - I’m actually physically trying to keep a patient alive…

I’m suggesting that, as I said before, the patient moving their head vigorously from side to side and my hands place – my hands in constant motion and changing position, trying to re-establish the airway and restrain him all at once, could be seen as – could be seen as something that it wasn’t”.