No small test dose and waiting to see the patient’s reaction before administering the full dose of anesthesia. The catheter to deliver the anesthesia should have gone about four inches into her lower back. Instead, he kept inserting the line, threading it in and up more than 13 inches. It mixed with her cerebrospinal fluid & stopped her breathing! Black women are nine times more likely to die of pregnancy-related complications.
https://www.nytimes.com/2023/01/23/nyregion/anesthesiologist-brooklyn-deaths.html