Patient complaints are an important source of information for service improvements. We audited patient complaints made about medical care in a National Health Service District general hospital over a 22 month period. Complaints were about medical care, nursing care, attitudes of staff, poor communication, clinical delay (9%) and hospital environment. The complaints department closed 66% complaints within 20 days. The majority of the complaints were directly related to clinical care, poor communication, attitudes of staff and nursing care. However, 99% of patients were satisfied with an explanation and an apology indicating that almost all have been due to a lack of good communication than due to real deficiencies in the clinical care. The hospital management has investigated the majority of cases within 20 days and has made several policy changes after the investigations.

No abstract

The diagnosis of phaeochromocytoma during pregnancy is rare. We present the management of vaginal delivery in a woman diagnosed with the condition during labour. A Medline search and follow-up of references failed to find any similar report in the last 30 years.

SummaryA patient r+,ith achondroplasia presented for elective Caesarean section under epidural anaesthesia. A block ,from C , to S, developed over 20 minutes after 12 ml plain bupivacaine 0.5%. This case serves to highlight the dificulties of regional anaesthesia in the gravid achondroplastic dwarf. Key wordsAnaesthetic techniques; epidural, lumbar. Genetic jactors; achondroplastic dwarfism.The anaesthetic management of the gravid achondroplastic dwarf offers a considerable challenge whether regional or general anaesthesia is chosen. The constricted maternal pelvis, marked lumbar lordosis and near-normal infant size make Caesarean delivery vital. Prompted by a request to perform an epidural in such a patient, we searched the literature but found little information with regard to doses of local anaesthetic drug or precisely how it should be administered. We discovered only two case reports, both from the United States, which involved the use of chloroprocaine 3.0%' and bupivacaine 0.75%.* There were no reports of the use of bupivacaine 0.5%. Case historyA 24-year-old achondroplastic dwarf was admitted for elective Caesarean section. She was gravida 3 with no live children. Her first pregnancy produced an achondroplastic boy delivered by Caesarean section but he died at the age of I 1 months as the result of a hyperextension injury to his neck. A subsequent pregnancy was terminated because of an antenatal diagnosis of achondroplasia.The patient presented for elective Caesarean section at 38 weeks' gestation and wanted to be awake during delivery. Previous anaesthetics had been uneventful; it was noted that it was easy to intubate her trachea with a 6.5-mm tube. This pregnancy was uncomplicated apart from mild hydramnios. Ultrasonic measurements of femoral length suggested that the fetus was normal. Physical examination revealed a 73-kg, 121-cm healthy female achondroplastic dwarf with short limbs, large cranium and a depressed nasal bridge. Her trunk was abnormal; she had a marked lumbar lordosis, impalpable lower lumbar vertebrae and prominent lower back musculature. She was unable to obliterate the lumbar lordosis either in the lateral or sitting position and had a markedly contracted pelvis which excluded the possibility of vaginal delivery. Her blood pressure was 110/75 mmHg in the lateral position. No other abnormalities were noted on examination. Results of pre-operative investigations were unremarkable except that the haemoglobin concentration was 9.3 g/dlitre; two units of packed red cells were transfused.The potential technical difficulties were discussed with the patient and she was prepared for the possibility that a general anaesthetic might be needed in the event of failure of epidural block. Thirty millilitres of 0.3 molar sodium citrate were administered, a 16-gauge intravenous cannula was inserted and 1.5 litres of compound sodium lactate solution infused. Epidural injection was attempted at the L,,, (?L,,J interspace. A 16-gauge Tuohy needle was used, but it was necessary to insert it at 45" cepha...

No abstract