Patient case 1 Mr. A suffered from an anal fissure for a while and was referred to a consultant surgeon Dr. X . Following a conservative treatment, Dr. X conducted an examination under anesthesia ( EUA ) with a view to lateral anal sphincterotomy . While performing the EUA, Dr. X attempted sigmoidoscopy ; however, the process was hindered by fecal loading. Then Dr. X used a Parks’ anal retractor and observed a benign-looking fissure . He excised a sample from the fissure for a biopsy test.
In addition to the fissure, Dr. X observed moderate vascular hemorrhoids . Next, he decided to treat the hemorrhoids by sclerotherapy . Dr. X took a syringe of phenol , which was filled by his assistant nurse at the operation theatre. Neither the nurse asked Dr. X to check the ampoules used to fill the syringe, nor did Dr. X ask to inspect the syringe or the ampoules. Dr. X started injecting the…
