Response to the Coroner’s Prevention of Future Deaths Report concerning Dr Rachel Gibson

We extend our deepest sympathies to the family of Dr Rachel Gibson, whose tragic death in 2022 was the subject of a coroner’s inquest concluded in August 2024.  

The coroner found that Dr Gibson sustained irreversible brain damage following cardiac arrest caused by administration of excessive local anaesthetic (Ropivacaine) during surgery. As a result, the coroner sent a Regulation 28 Report to Prevent Future Deaths to the College.  

We have reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG), a collaborative project between the Royal College of Anaesthetists, the Association of Anaesthetists and NHS England’s Patient Safety Team. A core objective of SALG is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK.  

In our response, we address the concerns raised by the coroner about the variation in the way local anaesthetic is prescribed, checked and administered in procedures where local anaesthetic is infiltrated into the operation site. It is essential that where this surgical technique is used there is a clear protocol in place that is understood and followed by the entire theatre team. Our response provides detail on what that protocol should include.   

In addition, we highlight that engineered solutions can reduce the risk of similar events occurring in future. We recommend that pre-filled syringes are used by default where available and outline steps that should be taken when manufactured pre-filled syringes are not available.  

We will disseminate the key safety messages detailed in our response through our regular Patient Safety Update, which is distributed to all members of the Association of Anaesthetists and Royal College of Anaesthetists. We have also contacted our surgical colleagues to agree these proposals and ensure that the same key safety messages are shared with members of the Royal College of Surgeons of England and the Royal College of Surgeons of Edinburgh.  

In the longer term, we will ensure that severe local anaesthetic toxicity secondary to surgical infiltration is captured in our forthcoming large-scale study on the complications of regional anaesthesia.  

We will do all we can to prevent similar tragedies occurring in future.