The incident, which took place at the Lidköping hospital, has prompted stinging criticism from Sweden’s National Board of Health and Welfare (Socialstyrelsen).
The 72-year-old went under anesthetic at 10.45am on the day of the operation, which took place in January 2011.
At noon sharp, the head anesthetist left the operating room to go for lunch. Fifteen minutes later, the head nurse anesthetist also left the patient and went for lunch.
No other anesthetist was called in to take over responsibility for the doctor who was on his lunch break.
And while another nurse was brought in to cover for the nurse anesthetist, the nurse who arrived came from the orthopedic ward and wasn’t familiar with the respirator to which the 72-year-old was attached.
Suddenly, the patient started hemorrhaging and his blood pressure started to drop, sparking a “chaotic” situation.
As the patient’s condition became critical shortly before 1pm, the substitute nurse tried desperately to reach the lunching anesthetist, but to no avail.
When the doctor and the primary nurse anesthetist returned to the operating room, they discovered that the patient’s respirator had been turned off, leaving him without oxygen for approximately eight minutes.
Despite immediately starting resuscitation efforts, doctors were unable to revive the man, who had suffered irreparable brain damage and died several weeks later.
The man’s daughter subsequently reported the incident to the health board, which on Tuesday issued a harsh critique of the hospital’s procedures.
“The operational planning, which allowed for the responsible doctor and nurse to take lunch breaks at the same time without any other doctor taking responsibility for the patient, entails taking an unacceptable risk,” the agency wrote in its findings.
The agency also found fault with the fact that the doctor wasn’t reachable by phone, as well as with the decision to hand responsibility for a high-risk patient with a single nurse who lacked sufficient knowledge of the equipment in use during the operation.
“The National Board of Health and Welfare finds, however, that the operation’s lack of organization as well as the chaotic situation which occurred was the underlying causes behind the misjudgments and insufficient care,” the agency wrote.