Coroner issues anaesthetic warning after death in Cambridge

In the report,, external he said: “The evidence was that the drug was sometimes specified in millilitres and sometimes in milligrams.

“This is of particular concern when the intention is for the drug to be diluted.”

In the case of Ms Gibson, an inquest found the intention was for a 2% solution of Ropivacaine to be diluted with normal saline before it was infiltrated.

Evidence suggested it was not done and an excessive amount of the drug was administered by mistake.

Mr Barlow said evidence suggested this type of practice was common nationally.

He added: “The hospital [Spire] has now introduced a system for labelling and countersigning the drug that was given during the operation.

“However, the evidence at the inquest was that, on a national basis, there is wide variation in the way local anaesthetic is prescribed, checked and administered in this type of procedure; and that it is common to use similar practice to that which occurred during this operation.

“This is why I believe I am under a duty to draw it to your attention.”