Delay to a patient’s surgery, due to lack of theatre availability, caused significant deterioration in their mental health. The patient was known to have mental health issues, and a plan had been made for pre-medication but due to the delay this did not happen. The patient was anxious prior to surgery and woke significantly agitated and upset. The ward team were unaware of the potential problem.  The patient was discharged home but later took an overdose at home with suicidal intent. The patient blamed this on how they felt when they woke up from the anaesthetic.

Commentary

Pre-medication is used less frequently now that day-case surgery and enhanced recovery protocols are the norm.  Where anxiolytic pre-medication is required, it is essential that there is clear communication between theatres and the wards to ensure that it is given in a timely fashion.  This case illustrates a potential consequence if this does not happen.