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"Poor experience with the communication and process of administering anaesthesia"

About: Royal Hospital for Children and Young People (Edinburgh) / Crichton Ward

(as a parent/guardian),

My little boy attended at the Crichton ward for surgery to open a blocked tear duct. The care he received was excellent for the most part, however we had a poor experience with the communication and process of administering anaesthesia.

On arrival, the anaesthesiologist assigned to my child met with us and explained that an attempt would be made intravenously in the first instance, and if that was not possible then gas would be administered through a mask. There was no further explanation in terms of the process of administering gas using a mask at this stage.

When we were taken through, the anaesthetist could not find a vein in my little boy’s hands. He was sitting on my knee calmly watching a TV show on my husband’s phone as a distraction while the anaesthetist searched for a vein. It felt very calm and child-centred. The anaesthetist then advised that their colleague was just outside and that they would ask them to check if they could find a vein.

The second anaesthetist entered the room and could not find a vein. My child was still sitting calmly at this point. There was then discussion in relation to administering gas instead, but rather than explain what was about to happen, the anaesthetist pointed to the top of a blanket and said - put his head here. I put my child on the blanket and he was then restrained in the blanket and pinned down on the bed with the mask placed over his face.

It all happened very quickly and without appropriate communication. I stroked his head to try and calm him down but he was absolutely terrified, going bright red with crying and writhing at being restrained in a blanket and pinned down. He cried, kicked and writhed so much that he managed to turn partially on his front. There were comments made along the lines of he’s really fighting it and it doesn’t usually take this long, which were not comforting. We had prepared for the anaesthetic to be a bit sad in that he would go to sleep, but the lack of communication meant we had not prepared for something which was quite frankly distressing and traumatic for all of us.

Had I known and had enough time to process that he would be fully restrained in a blanket and pinned down, I feel I would have advocated better for him. I struggle to understand why distraction methods were not used in the first instance with my husband holding him tightly sitting upright, and me assisting with the holding if necessary. There was no explanation given.

I hope consideration will be given to not using this method of restraint going forward- it felt inhumane and outdated, inappropriate for his age, and was distressing for all of us.

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Responses

Response from Louise Davies, Patient Experience Officer, Patient Experience Team, NHS Lothian last month
Louise Davies
Patient Experience Officer, Patient Experience Team,
NHS Lothian
Submitted on 09/10/2025 at 17:23
Published on Care Opinion at 17:23


picture of Louise Davies

Hi Chrtx33

Thank you for sharing your story on Care Opinion, I am really sorry to hear about your son's experience. I highlighted this to the Clinical Director for this service at the RHCYP, who has provided the below response:

"Dear Chrtx33,

I am really sorry to hear of your experiences whilst engaging our services at the RHCYP. I understand your concern and would thank you for bringing this to my attention.

I understand from your posting that your child attended RHCYP for an exploration of the tear duct under a general anaesthetic and that this did not go as you had expected.

General anaesthetics in children can be challenging, with the most frequently encountered challenge being to obtain intravenous (IV) access to allow us to administer the anaesthetic by this route. We prefer, where possible, to use this route as it allows us to provide a smooth and less nausea inducing anaesthetic, as well as enabling us to give any emergency treatments in the event of these being needed. For these reasons, we often try where possible, to achieve IV access before putting children under a general anaesthetic. However, this is sometimes difficult for a variety of reasons, most commonly the vein being too small to see, and to cannulate. Thus we often have to revert to using a gas to put children under general anaesthetic and quickly obtain the IV access as soon as possible after this.

We try to inform all patients and their families that this may be a possibility and what this will involve, but I am really sorry that this was not sufficiently explained in this case.

I have reminded the anaesthetic team about the importance of communicating what is happening to a child in our care with the family, to make sure everybody understand the plans, are content with these, and to discuss afterwards with the family what happened and answer any questions they may have.

I am sorry this was distressing for him and upsetting for you, and that it has left a negative opinion of the day on you and your family. This was not the intention of the team looking after your child.

I am happy to chat to you further if this would help to answer any questions you or your family may have around this event. If so, please get in touch with our Patient Experience Team by sending an email to loth.feedback@nhs.scot with your contact details and making reference to this Care Opinion story.

Kind regards

Dr Alistair G Baxter,

Clinical Director,

Anaesthesia, Theatres and Surgery,

RHCYP."

I hope it is reassuring for you to know the issues raised have been shared with the team for learning, but if you have any questions please feel free to contact the Patient Experience Team as mentioned above and we will pass on your details.

Thank you

Louise

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