The man went to a hospital in Lidkoping to have a tumor removed from his kidney in January 2011, The Local.se reported.
At 10:45 a.m. on the day of his surgery, the man underwent anesthesia, and at noon, the head anesthetist left the operating room for a lunch break. About 15 minutes later, the head nurse anesthetist also left for lunch.
No other anesthetist was brought in to take over responsibility for the doctor, however another nurse was brought in to cover for the original nurse.
Shortly thereafter, the patient started hemorrhaging and his blood pressure dropped; his condition became critical shortly before 1 p.m. The replacement nurse tried to contact the doctor and the primary nurse, but was unable to do so. When the pair returned from their lunch break, the patient had gone without oxygen for approximately eight minutes.
Despite an effort to revive the patient, he suffered irreversible brain damage and died several weeks later.
The man's daughter reported the incident to Sweden's National Board of Health and Welfare, which on Tuesday issued a harsh evaluation 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 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."
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