Critical Incident

Perioperative death is thankfully not a regular occurrence in UK operating theatres. However, when it does occur the perioperative practitioner is often denied the opportunity to grieve. The use of a clinical supervision session enabled a critical reflective approach to be followed after the death of a patient in the operating theatre.


Reflection is a critical component of the continuous professional development (CPD) cycle and enables practitioners to objectively review their practice thereby enhancing their performance (Taylor 2000). Reflection-on-action is a method of reflection that can be used following an event, to problem solve and examine solutions to situations. Reflection-on-action gives practitioners the opportunity to challenge current practice and encourages transformative action that can ultimately lead to improvements in the quality of care delivery.

Glaze (1998) refers to the difficulties that practitioners face in developing critically reflective skills due to the 'this is the way we have always done it' approach and suggests that nurses should engage with colleagues to develop critically reflective skills. This process of facilitated reflection can be referred to as clinical supervision. Clinical supervision has been highlighted by the Department of Health (DH) and other international health agencies as significant to creating and providing safer clinical practice (DH 2001, Haggman-Laitila et al 2007, Staun et al 2010). Using Gibbs' (1988) model of reflection this paper details the discussion from a clinical supervision session following a perioperative death.

Description of event

This event is centred on a patient requiring an emergency oesophagogastroduodenoscopy (OGD). The theatre team consisted of a consultant endoscopist, endoscopist registrar, theatre sister, two staff nurses, a 2nd year nursing student, anaesthetic registrar and anaesthetic nurse. The patient was a fifty two year old man, William Brown,...