Burnt buttocks – chlorhexidine skin preparation

A 45-year-old man was admitted to a private hospital for haemorrhoidectomy. The surgeon cleaned the area with chlorhexidine in spirit, applied disposable paper drapes and proceeded to carry out diathermy excision of a large posterior haemorrhoid. This was three-quarters removed when there was a sudden spark and a flash, the drapes caught fire and the patient's buttocks were burnt. An arc of fire also ignited the drapes on the nurses' trolley. The theatre staff poured cold water over the patient as well as over the burning drapes and the flames were put out within a minute.

The patient suffered superficial burns to the cheeks of both buttocks, amounting to nearly two per cent of his body surface. Needless to say, the operation was abandoned at this point. A week later, the patient was well enough to undergo a second operation which was completed successfully.

The patient's solicitors issued a claim against the surgeon and the equipment used during the operation was inspected. It was found to be satisfactory and had not contributed to the incident. While admitting full responsibility for the unfortunate events, the surgeon claimed that the chlorhexidine used to prepare the area for operation was thicker than that used in other hospitals and consequently did not evaporate as quickly. He suggested that the collection of the spirit in a pool underneath the patient was due to this difference and claimed that the hospital should have changed to a safer solution following a similar incident some months earlier in which a swab had caught fire during an operation. The hospital's legal advisers disputed the claim after having examined the material and equipment used during operations and finding them to be safe.

The MDU's surgical adviser agreed that responsibility for the injuries sustained by the patient lay with the surgeon who had performed the operation, stating that the previous incident could not be used to support any claim against the hospital. He said that, "the danger of solutions containing spirit being ignited by diathermy is a well-recognised hazard with which I would expect a surgeon to be familiar."

The case was finally settled for £10,000



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