Boy, 10, wins £5 million compensation after series of doctors' blunders left him needing a kidney transplant

A 10-year-old who had to have a kidney transplant after mistakes by doctors at a private hospital left him in renal failure, has today been awarded £4.8 million in compensation.

Lucas Tuppeny was born in January 2004 with a bowel defect, and required a colostomy, Judge Richard Parkes heard at London's High Court.

A series of errors by medical staff at the Bupa Cromwell Hospital in Kensington, London, resulted in Lucas suffering renal failure.

It left the youngster needing dialysis from the age of six months.

In October 2005 he received a kidney from his father, Brock, who works in the oil industry.

Lucas, who lived in Ruislip, Middlesex, at the time but is now settled with his mother, Therese, in Seattle, in the U.S., has had 28 procedures with a total of 149 days in hospital.

And he will need another transplant in the future, the court heard.

In spite of his problems, Lucas is an 'enthusiastic, optimistic, energetic and very sociable little boy', Christopher Johnston QC said.

Asked how he was feeling by the judge, Lucas stood and said 'Good, your Lordship', adding he would be having a holiday in the Bahamas before going back to school.

The judge, who approved the settlement against the hospital, which admitted liability, said: 'I am delighted to hear it.

'It is lovely to see you and I would just like to wish you all the best for the future.

'You are very lucky in your mum and your dad.'

Both the judge and the hospital's counsel, Jeremy Hyam, paid tribute to the outstanding care shown by Lucas's mother.

The judge, who had seen a video about Lucas, told Mrs Tuppeny: 'What extraordinary devotion you have lavished on your son throughout these difficult years.

'I don't think anyone on the outside would know what is involved.

'One can only watch with huge respect what you and indeed your former husband have done.

'Having seen the video makes one realise what a splendid young man Lucas is and what potential he has, thanks to you.'

Alison Eddy, a partner with lawyers Irwin Mitchell, said outside court: 'It is a huge relief for his family that the hospital and medical staff who cared for him have now agreed an adequate and fair settlement to cover his care needs both now and in the future.

'This young boy has suffered a catalogue of medical issues throughout his childhood and will face numerous problems in his future as his condition deteriorates.

'We are pleased that we secured this settlement for him and his family, who now have the financial security and reassurance that costs for his future treatment will be met.

'We hope that lessons are learnt by the hospital and their staff so that patient safety in this situation can be improved and each and every patient receives the best quality of care at all times.'

The damages will cover Lucas's medical and care costs and anticipated future loss of earnings.

A spokesman for the Bupa Cromwell Hospital told MailOnline: 'We did not own the hospital in 2004.

'However, we are very sorry that Lucas suffered these problems and would again like to apologise to him and his family.

'We hope that this settlement will give Lucas and his parents the security of knowing that his future care and support needs can be met.

'We wish Lucas and his family well for the future.'

This article is courtesy of the Daily Mail.

Staffordshire hospital admits liability after woman dies of blood poisoning

Ethel Sanders from Burntwood died at Queen’s Hospital in Burton after suffering from multi organ failure, internal bleeding and blood poisoning due to a two-month delay in receiving surgery and poor care afterwards.

Now the hospital has admitted its mistakes and agreed to pay her family a five-figure sum as compensation.

Her daughters today called on Burton Hospitals NHS Foundation Trust, which runs the hospital, to improve services for the elderly after she suffered months of agony before her death.

The trust has admitted breaching its duty of care to the 85-year-old and has agreed to pay the family an undisclosed five-figure settlement.

Expert evidence commissioned by medical negligence lawyers at Irwin Mitchell found there was a two-month delay in Mrs Sanders having surgery to treat colovescial fistula - a condition which affects the colon and the bladder causing pain and infection.

It also discovered when she did have keyhole surgery to treat the problem, it was performed negligently causing a tear to the ovarian vein.

It was not until the following day that doctors diagnosed her deteriorating condition as being linked to the tear and despite further surgery, it was too late and she died a week later in March 2011.

Mrs Sanders' daughters Linda Ward and Sandra Neal say they remain 'deeply concerned' by standards within the trust and said lessons must be learned.

The trust was placed in special measures by the Care Quality Commission last year as part of a review into death rates at a number of hospitals across the country.

Mrs Ward, aged 61 and from Hednesford, said: "We remain devastated by the loss of our mum - it was extremely difficult to see her suffer like she did. She was in absolute agony for weeks but there seemed to be no hurry to try and help her and we felt completely helpless.

"From start to finish my mum did not receive an acceptable level of care and it is simply not good enough. What makes us so angry is that the trust is clearly not making good enough improvements as it is one of the few hospitals to remain in special measures.

"Mum was vulnerable and elderly and should have been treated with compassion and integrity but we saw none of that and it is heartbreaking to think of how she suffered.

"Action must be taken to improve services for both the elderly, and patients in general to prevent anyone else from going through such a horrific ordeal and to restore faith in the services it provides."

Dr Craig Stenhouse, medical director at the trust, said "This is an extremely sad case and we are truly sorry that the care and treatment given to Mrs Sanders was not of the standard that our patients deserve.

"We completely accept that the quality of care provided was inadequate and we have taken immediate action to make changes."

This article is courtesy of the Express and Star.

Facelift scarred me for life: Pensioner tells of botched operation ordeal

A pensioner has told how she was left scarred for life following a botched facelift.

Pearl Richman was awarded more than £43,000 in compensation after her life was ‘almost ruined’ by a procedure carried out in 2010.

After the operation, the 69-year-old developed necrosis – a form of cell injury which results in the premature death of skin cells – and was left with open flesh wounds.

But despite a court finding in favour of Mrs Richman and awarding compensation, she says she still hasn’t received a penny and the surgeon, from Italy, is still believed to be operating in the UK.

Mrs Richman, from Kenilworth, took her civil case to a county court hearing in April, where a judge awarded costs against the doctor for negligence.

Now Mrs Richman is calling for the government to take action over ‘seagull surgeons’ – foreign doctors who fly into the UK and undertake failed procedures before returning home.

“This might sound dramatic to people, but this has almost ruined my life,” said Mrs Richman.

“I always took pride in my appearance and over the years I went from having lots of photos of myself around the house, to having none.

“I had talked about having a facelift but they are expensive and we didn’t have the money. My kids had always talked about buying one for me and one year my daughter Jo, who has her own business, was able to do just that.”

The company which organised the £8,000 facelift has now gone into administration. The centre introduced Mrs Richman to an Italian surgeon before she underwent the procedure at a hospital in London.

She added: “He never talked about necrosis at all. It wasn’t mentioned. He talked about the normal risks but at no point at all did he mention necrosis. I just remember him saying that he would make me happy.

“When they took the drains out of my face it hurt so much, I screamed and it started to go purple. It went from a large purple bruise to a huge black scab that had the feel and look of leather.”
The company contacted the surgeon in Italy and he arranged an emergency appointment with Mrs Richman.

She said: “When he saw me he took me straight into a treatment room and said it had to be treated like first degree burns. He told me he was so sorry and that it did not happen very often.

“He offered laser treatment which I had and he said he would do everything he could to make it better and put it right. That is the last we have ever heard from him.”

Medical negligence solicitor Jeanette Whyman, of law firm Wright Hassall, is now pursuing the case.
She said: “I am aware of ‘seagull surgeons’ but have not come across the issue to such a horrific degree. He does have insurers but because he has not notified them of the incident, they will not cover him.

“His residency outside of the UK shouldn’t, in theory, make a difference. What it means is we can get a judgment here but it has to be enforced abroad which can be expensive. If there are no assets in the UK, you cannot enforce here and it has to be pursued abroad.”

Mrs Richman is now urging anyone contemplating surgery to undertake extensive checks.
She added: “Surgeons should not be limited to their country but the government should make sure there is a level of accountability through qualifications and insurances.

“Clinics should also be responsible for the actions of the surgeons they use.  would not want (this) to happen to another single person.”

This article is courtesy of Wright Hassall.

Awareness during surgery can cause long-term harm, says report

At least 150 and possible several thousand patients a year are conscious while they are undergoing surgery in the operating theatre, according to a report which warns that some people suffer long-term psychological damage as a result.

In the vast majority of cases, patients have been given muscle-relaxing drugs that temporarily paralyse them, preventing them from warning theatre staff that they are awake. It happens most often during caesarean sections under general anaesthetic and during heart surgery.

A three-year investigation carried out by the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland found that usually the experience of awareness was short-lived, at the beginning or end of the operation.

Half of those who were aware of what was happening to them were distressed by the experience, and 41% said they suffered long-term psychological harm. The sensations they experienced included tugging, stitching, pain, paralysis and choking.

Patients described feelings of dissociation, panic, extreme fear and suffocation. Some said they feared they had been entombed, buried alive or were dead.

Prof Jaideep Pandit, consultant anaesthetist at the John Radcliffe hospital in Oxford and one of the authors of the report, said the Royal College and Association had "recognised the problem officially for the first time".

He said: "For a long time it has been a discussion on the periphery. This is real. We need to understand it and tackle it."

Not all experiences were traumatising, he said. Some patients spoke of feeling removed from what was happening. The drugs did not cause unconsciousness but made them feel detached. Sometimes they felt this was acceptable, and Pandit said there was an unanswered question as to whether all patients would want oblivion during surgery or whether some might prefer pain-free awareness.

It was vital, however, he said, that patients are told before they have surgery that there is a possibility, however remote, of having some consciousness of what is going on.

Estimates of how often this happens vary, says the report. When patients are asked after surgery whether they had any awareness, one in 600 say yes. But only one in 19,000 will come forward to talk about it voluntarily after the surgery. That would put the numbers at between 150 and 4,500 a year.

The team looked at three million episodes where a general anaesthetic was given in a hospital and reviewed in detail 300 cases of awareness reported by patients.

In 97% of cases, patients received muscle-relaxing drugs as well as the general anaesthetic. This makes it harder for an anaesthetist to be sure the patient is unconscious.

Around 10% of cases were caused by drug errors. In some, the muscle relaxant had been given without the general anaesthetic, which meant the patient was fully conscious but paralysed throughout their operation.

Where that happened, says the report, there were organisational as well as individual errors. "These included ill-considered policies for drug management, similar-looking ampoules, poorly organised operating lists, high workload, distraction and hurriedness," says the report.

"These patients were severely distressed and severely harmed in the long term," said Pandit. The report recommends a checklist before surgery, which would require the anaesthetist to line up the drugs they intend to administer and point to each one in turn. Pandit said mistakes "seem to occur in a highly pressured environment"

This article is courtesy of The Guardian.

NHS faces huge compensation bill after dozens of patients were left with sight problems when it hired private firm to complete cataract surgery

A hospital could face a huge compensation bill after it hired a private firm to remove cataracts and half the patients treated suffered complications.

Musgrove Park Hospital in Taunton hired private provider Vanguard in May to help reduce a backlog.

But the hospital terminated the contract after only four days after 31 of the 62 patients who had the operation reported complications including blurred vision, pain and swelling.

One 84-year-old man claimed he has lost his sight and his family is calling for a full independent inquiry.

Some of the patients, including the 84-year-old man, have contacted lawyers to discuss seeking compensation, which raises the prospect of an NHS hospital picking up the bill for procedures done by a private health company.

Taunton and Somerset NHS Foundation Trust refused to talk in detail or discuss pay-outs when approached by The Guardian Newspaper, but a senior member of staff told the local newspaper that the hospital would be liable for any payments.

Colin Close, Musgrove Park’s medical director, told the Somerset Country Gazette: ‘Any financial responsibility would rest with us.

‘If any patients wish to pursue compensation, we would work with them.’

He added: ‘We still don’t know exactly what the cause is – we’re trying to identify that at the moment. There could be a range of causes.’

Dr Close said he would normally expect one in 400 patients to experience these complications.

A spokesman for Musgrove Park told The Guardian: ‘Due to the ongoing nature of our investigations it would be inappropriate for us to comment on the sequence of events surrounding the unfortunate complications experienced by our patients receiving cataract surgery with Vanguard Healthcare in their mobile theatre onsite at Musgrove Park hospital.
‘Our first and foremost concern has always been our patients, and particularly those who have experienced complications.

'We have been in very close contact with them since the incident to ensure they are fully informed with our progress and receive the highest quality aftercare and treatment.

'We will want to discuss the outcomes of our investigations with them first, once they have reached conclusion.’

Ian Gillespie, chief executive of Vanguard Healthcare Solutions, said: ‘Patient care is our number one priority and we’re working closely with the trust to understand and fully investigate the root causes of any complications.

‘This investigation is still ongoing, making it inappropriate to comment on specific issues or on individual patient cases.

'Operations were carried out in Vanguard’s operating theatre by highly qualified surgeons, approved by the hospital, and with many years’ experience of working in the NHS.’ 

This article is courtesy of the Daily Mail.

Surgeon rendered patient infertile by giving him a vasectomy by mistake during minor operation

A surgeon has rendered a patient infertile by giving him a vasectomy when he went into hospital for a minor operation.

The patient was the victim of what hospital chiefs have called a 'never event' - a medical mistake that should never happen.

The man, who had the original procedure at Broadgreen Hospital in Liverpool earlier this year, has been told that an operation to reverse the vasectomy was unsuccessful. He could now be entitled to more than £100,000 in compensation.

It is understood that the surgeon who performed the surgery has since been fired, according a report.

The urology department at Broadgreen Hospital, part of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, has admitted the error was just one of five botched operations - and two 'never events' - in the last 12 months.

Another mistake involved a medical swab being left inside a patient during an operation.

The Royal Liverpool Hospital 'apologised unreservedly' to the man when details of the mistake, which they termed 'wrong site surgery', emerged earlier this year.

The vasectomy - and the failed reversal - means that the patient will not be able to conceive naturally.

Ian Cohen, clinical negligence lawyer at Slater & Gordon, said the vasectomy patient could be eligible for more than £100,000 in compensation, but it would depend on how old he is and whether or not he has been left infertile.

Mr Cohen said: 'This is a truly shocking and worrying case. From what we know there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.

'If a 25-year-old who wants a family is told he won’t be able to father children, it will be devastating.'

Hospital bosses say the blunders have been reported to NHS chiefs and that investigations are under way to establish how they happened.

Dr Peter Williams, medical director at Royal Liverpool and Broadgreen University Hospitals NHS Trust said: 'Our urology department is the biggest in Cheshire and Merseyside, caring for over 4,000 patients a year.

'The vast majority of feedback from these patients is overwhelmingly positive.

'We have excellent, highly regarded clinical teams who treat the most difficult urological cases, many of which are referred to us by other hospitals for our expertise and leading edge surgical techniques.

'In the last 12 months, three serious incidents and two never events occurred in our urology department and these were reported to the appropriate bodies.

'We are still in the process of investigating some of these incidents, including looking at how to improve the processes and systems in place and are taking appropriate action.

'We cannot comment on the outcomes of these investigations at this stage.

'Patient safety is always our priority and we use the lessons learnt from any incident to continually improve our standard of care.'

This article is courtesy of the Daily Mail.

Wrong site surgeries remain top hospital mistake

The surgeon(s), anesthesiologist, scrub nurse, circulating nurse, the surgical techs, and residents stand in the surgical suite. Also in the room is a patient prepared for surgery. The team is going to amputate his lower left leg because he has complications from diabetes. Before performing the procedure, the surgical team forms a huddle to review the surgery that is before them and to ground themselves. When the surgery is completed, instead of the patient’s lower left leg being amputated the team amputated the patient’s lower right leg.

Though statistics vary widely, The Joint Commission, an organization which governs the accreditation of health care organizations, suggests that wrong site surgeries occur 40-60 times in the U.S. each week. Wrong site surgeries are considered to be sentinel events, unexpected occurrences involving psychological injury or serious physical injury or death . The Joint Commission requires sentinel events to be reported and investigated so that the root cause of the mistake can be determined. According to the governing body, breakdown in communication is the primary culprit for wrong site surgeries. After analysis, it has been found that 85 percent of wrong site surgeries occur because of inadequate planning. 72 percent have been attributed to defects in surgeons’ “time outs.” Surgeon “time outs” are breaks taken before a procedure begins, to ensure that all of the details regarding the forthcoming surgery are correct.

Most wrong site surgeries occur during orthopedic, urologic, and neuro-surgical procedures. Odds of wrong site surgeries increase when the surgery involves multiple procedures. For example, when a trauma patient has multiple fractures, surgical teams may make mistakes on which sites require operation.

“Around the country, surgical teams have adopted the practice of forming these huddles or time outs before surgeries,” said Sara Perkins, a Manager of Employee Health at a local hospital in Vancouver, Wash. Perkins, however, is not a surgical nurse. Speaking about the time out procedure her hospital utilizes, Perkins said, “The objective is to confirm that the patient before the team is going to receive the surgery that is needed. The time out leader explains how the surgery will go and questions are asked and answered before the first incision is made.”

Despite time outs, wrong site surgeries continue to occur throughout the nation’s operating rooms. Sometimes the time outs simply do not take place, as may be the case in a severely life-threatening trauma situation where minutes count in saving the patient’s life. Other times, distractions arise and make it difficult for the whole team to come together. The phone might ring. Previous procedures may go longer than expected, making some team members later to the surgical suite than would be optimal. Staff may be rushed, moving between procedures, so that not all team members are fully engaged in the time out.

In small hospitals that do not have multiple surgical teams, an emergent trauma can require team members to toggle between patients. Surgical suites are generally kept small and cool to facilitate a sterile environment. Exchanging team members after the patient has been prepped and draped has the potential of breaking the sterile environment and is discouraged; nevertheless, it sometimes happens. The new staff may not be fully briefed, unlike the team that was present during the pre-surgical timeout.

The Joint Commission requires healthcare to report them and investigate the root causes as to why each of these events have occurred. Medicaid’s decision to deny funding for procedures and care resulting from wrong site surgeries is fairly new. This effectively puts the financial burden of care for these patients back onto the shoulders of hospitals. Despite this further incentive to only perform surgeries on patients that are needed, wrong site surgeries are still one of the biggest mistakes that hospitals make.

A brochure published by The Joint Commission is listed in the “Sources” section at the end of this article. The brochure suggests that to help reduce risk of medical mistakes and wrong site surgeries, patients should consult with their healthcare provider before surgery, to make sure that they do not take any medication that will create ill effects during or after surgery. Also, the patient is advised to make sure that markings placed on their body before surgery accurately reflects the body part on which the surgery is to take place. The video below demonstrates the World Health Organization’s (WHO) protocol for conducting a pre-surgical time out. Team members identify themselves, their roles, and the procedure that is going to take place. This procedure has reduced the incidence of wrong site surgeries, though they continue to occur.


This article is courtesy of the Liberty Voice.

Medical innovation under the microscope - the Saatchi Bill

Following the death of his wife in 2011 from ovarian cancer, Lord Saatchi introduced a Bill which would allow doctors to offer patients suffering from diseases or conditions that were not responding to conventional medicine, innovative treatments that had not necessarily been subjected to rigorous testing.
 
The underlying motivation for the Bill is the belief that many doctors are deterred from trying new procedures for fear of being sued for medical negligence. The arguments for and against the Medical Innovation Bill, more commonly referred to as the Saatchi Bill, are heated: proponents argue that doctors’ hands are tied by guidelines which are too prescriptive – even when tried and tested treatments are no longer working; while opponents believe that the current law does not stop doctors trying new procedures but does, more importantly, protect patients against irresponsible experimentation.
 
The Saatchi Bill – what it proposes
 
Jeanette Whyman, Head of Medical Negligence with Wright Hassall comments “On the face of it, it is perfectly understandable why Lord Saatchi has proposed this Bill. He lost his wife in painful circumstances and is strongly of the opinion that the medical profession is shackled by the fear of litigation making doctors unwilling to try remedies that might help in individual cases”. The Bill has proposed safeguards to ensure that the "doctor who acts alone and in a reckless way" is exposed as a maverick (that word plus the use of ‘quackery’ is used a great deal by both sides and reflects the emotional undertone of the debate).  One such safeguard is that any doctor proposing an innovative treatment must seek the agreement of a multi-disciplinary team with expertise in the relevant area and his / her Responsible Officer in order to proceed. By doing this, supporters of the Bill argue, doctors are applying the principle of the Bolam test (whereby they must, if accused of medical negligence, establish that they acted as any other responsible medical professional would have done under similar circumstances) in advance of the treatment rather than retrospectively. Lord Woolf, himself a supporter of the Bill, believes that it is not a ‘charter for risky experimentation’ but a genuine desire to improve the treatment for those for whom all else has failed.
 
Do we need the Saatchi Bill?
 
According to a long list of eminent organisations and individuals, the answer is no, or at least not in its current format. The Medical Defence Union (MDU), the NHS Litigation Authority, the Royal College of Physicians, Sir Robert Francis QC and Cancer Research UK, among many others, all refuted suggestions that fear of litigation was holding the medical profession back from innovating. Indeed, many of the comments received from the public consultation suggested that this Bill would actually protect maverick doctors who, having harmed a patient by trying an untested treatment, could avoid a claim for medical negligence by retreating behind this Bill which had essentially allowed the experimentation. Opponents of the Bill argue that the current law is able to differentiate between responsible medical practice and incompetence - which is not the same thing as stifling innovation - thus making further legislation unnecessary. They also make the point that many patients who are likely to consent to a new treatment are often desperate and thus vulnerable to persuasion by doctors willing ignore responsible medical opinion. Claims by supporters that it will help to further research into rarer cancers and diseases which, they maintain, are currently overlooked by larger research projects are also challenged by opponents. Cancer Research UK notes that research into effective treatments has to be scientifically robust if it is to benefit the majority. Experimentation on individuals will be of limited benefit although a project team at Oxford University has offered to store data from individual cases enabling them to map trends.
 
In short
 
The government, while supporting this Bill in principle, has acknowledged its shortcomings and has committed to incorporating amendments to overcome objections raised by opponents. However, judging by a recent announcement by Dan Poulter when he outlined the likely changes, the proposed legislation will offer nothing more than the current law. I think what this debate has helpfully highlighted is that doctors who do their job responsibly do not fear medical negligence claims and are not dissuaded from pursuing innovative treatments if they genuinely feel they will make a difference to the patient. This Bill, if it becomes law, could end up protecting doctors who actively harm patients by going out on a limb to carry out untried and untested remedies – which is the opposite effect of what it is trying to achieve. The Bill has now reached the Committee stage where it will be examined in detail against the backdrop of responses received from the public consultation which closed in April.
 
This article is courtesy of Jeanette Whyman, who heads up the team of Medical Negligence Solicitors with Wright Hassall.

Grandmother wins £250,000 after botched hip operation left her leg pointing in the wrong direction

A grandmother who was left with her foot pointing 90 degrees in the wrong direction after a surgeon botched her hip operation has won £250,000 in damages.

Brenda Gorst developed a life-threatening infection and her leg was left shorter following blunders by a consultant at Abergele Hospital in North Wales.

Since her surgery in October 2007, the 73-year-old has endured six major operations to try to correct the problem and faces further procedures to rebuild her femur, hip and pelvis.

Mrs Gorst began suffering aches and pains in her hips in her 60s, and was recommended for hip replacement surgery.

She said: 'When I woke up from the operation, my leg was black and I was in agony. It took some time to realise something had gone badly wrong.'

The pain and swelling in her leg did not subside, and a revision operation was proposed.

She said: 'After the second operation, it became obvious that my right foot had started to point east. They tried to put my foot straight using sandbags.'

During one of the operations, Mrs Gorst, who now lives in Newton-le-Willows in Merseyside but used to live in Rhos-on-Sea in Wales, contracted an infection.

She claims that when she was sent for a second opinion and an X-ray, the new consultant was visibly shocked at what he saw.

Mrs Gorst said: 'I was in acute pain, the bruising and swelling was terrible and my leg was twisted in entirely the wrong direction.

'At that point they thought I had a flesh-eating disease. They told me I could be dead in three days. It wasn’t a flesh-eating disease, but it was still a vicious infection.

'My leg is virtually useless. I’ve gone from someone who was active to someone who is unable to do many of the things I used to take for granted.'

The hip replacement has since been removed but her leg bone is now fused to the pelvis, shortening Mrs Gorst’s leg by four inches.

She won damages following a legal battle with the Betsi Cadwaladr University Health Board.

Her lawyer Daniel Lee, of Slater & Gordon, said: 'Her mobility and activity are dramatically reduced as a result of the operation which was meant to give her a new lease of life.'

Professor Matthew Makin, executive medical director at Betsi Cadwaladr University Health Board, apologised for the distress caused to Mrs Gorst.

He said: 'On behalf of the health board, I am sorry that the care Mrs Gorst received at the time fell short of the standards she deserved.

'We aim to provide excellent care and have looked carefully at this case to make sure mistakes are learned from and cannot be repeated.'

This article is courtesy of the Daily Mail.

'Black box' tracks errors in Toronto operating room

A “black box” installed in a Toronto operating room earlier this year has found that surgical teams are making the vast majority of their errors during the same two steps surgery after surgery.

Now researchers are looking at how to reduce those mistakes and prevent similar slips in the future.

Dr. Teodor Grantcharov, who developed the operating room black box compares using the technology to learning how to golf.

“Usually we can’t appreciate our performance while we’re in the middle of the operation,” said Grantcharov, a surgeon at St. Michael’s Hospital. “You swing and you think you’ve done a great job and someone video records it and shows you how you’ve done and obviously there are so many things to improve.”

Three microphones and three cameras began recording all of Grantcharov’s surgeries at the end of April as part of the black box project. Two of the cameras film the operating room, while a third internal camera records what’s happening inside the patient’s body while the surgeon and his team perform minimally invasive surgeries. The video and audio collected is then analyzed by a team, who look at surgical techniques, the surgical team’s communication and how they work together, and what kind of hazards exist in the operating room.

An initial pilot recorded about 80 gastric bypass surgeries and found that 86 per cent of the errors were made during just two steps: suturing and grafting the bowel.

That information was very valuable, Grantcharov said, and a team is now working on creating educational tools based on the data.

“If we know where the errors happen, then we will know what to do to avoid them in the future.”

There are small errors in every surgery, but that doesn’t mean that a patient’s safety is compromised, Grantcharov said. An error could be something as simple as a surgeon losing sight for a split second of a needle while suturing.

“Error, for us, is minimal, the smallest deviation from the perfect course,” he explained. “In the vast majority of cases, it is nothing. The patient will recover perfectly and nobody will ever know that there has been an error.”

Traditionally, however, error hasn’t been discussed in surgical culture, Grantcharov said. He’s hoping having black boxes in operating rooms will help promote a safety culture similar to that of the aviation industry, where people can speak freely about mistakes and point out things they believe could be done better.

“I think it’s acceptable, it’s just human, that we make errors,” he said. “It’s not acceptable not to do anything about it.”

Reducing slips in the operating room will not only make surgery safer for patients, but it will help cut costs, too, said Grantcharov. If surgeons make fewer errors, they’ll be able to operate more quickly and do more surgeries in a given time period. Preventing errors will also cut back on adverse events — injuries that need to be fixed — which also saves money, he explained.

Currently St. Michael’s is the only hospital with the black box technology, but other hospitals have said they, too, want to try out the cameras and microphones. Grantcharov hopes black boxes will be installed in some European hospitals soon, and wants the technology to eventually spread to a wide variety of procedures in operating rooms around the world.

So far, surgical teams at St. Michael’s have been open to the black box project, and they see the potential learning and safety benefits, Grantcharov said. But there is potential for the technology to be used in less positive ways, such as recording evidence for use in malpractice lawsuits.

“If we choose to use it as a tool to place blame and to point fingers at surgeons for litigation, I think this will never take off,” Grantcharov said.

“It’s important that we use this constructively, that we use this to improve our selves, to become better surgeons and safer surgeons and improve the outcome for out patients. If we use it in this direction, I think this will change the way we practice.” 

This article is courtesy of the Brampton Guardian.

Wirral transplant patient wins payout over kidney from donor with cancer

A man who was given a cancerous kidney in a transplant operation has been awarded a six figure compensation settlement from the NHS to help him to rebuild his life.

Robert Law, 62, of Wirral, Merseyside, endured gruelling chemotherapy and was left psychologically scarred after a communication error lead to him receiving a kidney from a woman with an aggressive form of cancer.

"The past few years have been incredibly stressful and traumatic so I am relieved I am finally able to start the process of moving on with my life.

I continue to believe in the vital work that the transplant service does and remain grateful that the family of the woman who donated the kidney made the difficult decision to pass her organs on to people on the transplant list.

I hope that lessons have been learned from my case and that this has helped to make the system safer by ensuring all medical staff involved with transplants have the training and support they need." – Robert Law

Mr Law underwent the transplant operation on November 26, 2010.

However 12 days after the surgery he was given the devastating news that an autopsy had revealed that the donor had intravascular B cell lymphoma.

Tests later confirmed that the kidney Mr Law had been given was cancerous.

"Mr Law was on the transplant list after suffering from kidney disease for five years.

His sister had offered to donate one of her kidneys but after a kidney became available from a deceased donor he decided to spare her the ordeal.

Unfortunately the donated organ gave him cancer, which psychologically has taken an enormous toll on him.

Despite this Mr Law has conducted himself with great dignity throughout this case and has spoken out several times in support of organ donation.

In my experience as a medical negligence solicitor this type of error is rare but as with the many others we deal with it could have been avoided with adequate training, monitoring and communication.

It would be a further tragedy for anyone else to go through such an ordeal so it is vital that lessons have been learned." – Eddie Jones, Head of Medical Negligence at JMW Solicitors.

Mr Law's solicitor secured an admission of negligence and an apology from NHS Blood and Transplant.

This confirmed that when the transplant was carried out there had been a failure to communicate to the Royal Liverpool and Broadgreen University Hospital NHS Trust the possibility that the donor had lymphoma.

A six figure settlement has now been negotiated for Mr Law to help him to cope with the fall-out of the error.

The settlement has been calculated to take into consideration the losses Mr Law suffered due to the negligence and his current and future care needs.

I would like to reiterate to Mr Law how sorry we are that this mistake was made. I hope the full and final settlement of his case means he can move on from what unfortunately happened.

I would also like to reassure Mr Law we have learnt lessons and have made a number of changes as a direct result of this case. – Lynda Hamlyn, Chief Executive of NHS Blood And Transplant.

This article is courtesy from ITV News.

Bristol NHS branded 'disgusting' over heart surgery issues

The mother of a boy who died after heart surgery in Bristol has said continuing NHS issues are "disgusting".

Luke Jenkins' parents have recently discovered his death was not correctly recorded in official figures submitted by the Bristol Children's Hospital.

They complained to the medical director of the NHS and a personal reply email admitted there had been a data error.

Bristol's NHS trust said it was unaware how the error had occurred but it would ensure it would not happen again.

It has now been corrected with the trust highlighting the hospital's 30-day mortality rate for the Fontan procedure - a type of heart surgery - "remains entirely within the expected range."

Seven-year-old Luke, from Cardiff, suffered cardiac arrest and died following heart surgery in March 2012. He had been expected to make a full recovery.

For that year the original statistics held by NICOR - the National Institute for Cardiovascular Outcomes Research - incorrectly suggested there were no deaths of children who had Luke's same heart operation.

The death rate statistics are crucial to the NHS as they highlight potential dangers around surgical units.

Faye Valentine, Luke Jenkin's mother, said: "This is the last thing we need. To keep having to prove what they're doing is wrong - they should be recognising their own mistakes.

"It's not for us to be pointing out where they've gone wrong. They shouldn't be putting us through this.

"They've put us through enough taking Luke, and to put us through extra stuff as well which isn't needed is pretty disgusting."

NICOR said a "detailed chronological investigation dating back to 2012" was under way to explore why the error had occurred.

Bristol University Hospitals NHS Foundation Trust said: "We take the recording and monitoring of mortality data very seriously.

"From our own initial investigations it has not been possible to fully determine how this error occurred.

"As such we have suggested that a joint investigation is carried out, involving both NICOR and the Office for National Statistics, who provide data to NICOR, to establish how this error occurred and to ensure that stringent measures are in place to prevent a recurrence."

Last month Prof Sir Bruce Keogh, medical director of the NHS, announced an inquiry would be held into the deaths of children following heart surgery at Bristol Children's Hospital.

A number of families had met with him to share their concerns about the care received by their children in the hospital.

This article is courtesy from the BBC.

Compensation over child hospital death

The parents of a child who died in hospital after undergoing an appendix operation are to receive £40,000 compensation, it has been announced.

Ray and Marie Ferguson reached an out of court settlement with the Western Health and Social Care Trust over the death of their daughter Raychel.

The nine-year-old died in June 2001, following her admission to Altnagelvin Hospital. She was administered a lethal dose of intravenous fluid after her appendix was removed.

Her death was investigated as part of the Hyponatraemia Inquiry, a condition which causes the brain cells to swell because of a low level of sodium in the bloodstream.

After her operation, Raychel was transferred to the Royal Belfast Hospital for Sick Children where she died hours later. Last year the Western Trust finally admitted liability and issued an unreserved apology to her family.

A medical negligence claim lodged at the High Court in Belfast was due to decide the level of damages to be awarded to Mr and Mrs Ferguson.

But Mr Justice Gillen was instead told that a settlement had been negotiated, with the family to receive £40,000 plus their legal costs.

Outside the court Mrs Ferguson stressed she was far from satisfied with the outcome, describing the compensation as "an insult".

Had the case gone to a hearing on the amount to be paid out, the family may not have got any more than the statutory limit of £11,800 to compensate the death of a child.

Mrs Ferguson insisted the law needs to change: "It's absolutely ridiculous. Some people would actually have got that (£11,800) for a whiplash claim.We are talking about the loss of a child. That's the most horrendous thing that can happen to anyone.

"The money is not going to bring my daughter, but it's just part of the legal system."

Raychel's death was one of five examined by the inquiry held in Banbridge, Co Down.

A report setting out its findings is awaited. Mrs Ferguson pledged that her family's legal battle may continue, with a possible further lawsuit against the Belfast Trust.

She confirmed: "It doesn't end here today. I'm going to fight on, and one of the things I'm going to fight for is the statutory amount (of compensation)."

This article is courtesy from U.TV.

Forty men left without TESTICLES due to botched medical care win payouts from the NHS

Almost 40 men have won compensation claims against the NHS in the last two years after botched medical care meant doctors needlessly removed one of their testicles.

In the majority of cases, surgeons had to remove a testicle that could have been saved if a man had been diagnosed earlier.

But in a handful of horrifying cases, doctors have removed the wrong testicle in a surgical blunder and then have to operate again to remove the other one when the mistake is discovered - leaving the man with no testicles.

The NHS typically pays out around £20,000 when it admits it is at fault for leaving men as monorchid - the medical term for having just one testicle.

But payments for removing a man’s only healthy testicle in a surgical mix-up can be around £70,000 as the individual gets compensation for being left infertile.

Often the compensation figure includes a sum to pay for cosmetic surgery to provide the men with a false testicle.

Figures from the National Health Service Litigation Authority (NHSLA) show that in the last two years 38 successful cases have been brought by men who claimed they were victims of botched surgery on their testicles.

In total £815,000 was paid out by the NHSLA in those cases, meaning the average payout has been around £21,000.

Last year a 48-year-old company director, who didn’t want to be named, revealed he was bringing legal action against Salisbury District Hospital after he had a healthy testicle removed by mistake.

He had gone into theatre expecting a cancerous testicle would be removed, but 40 minutes after the operation a doctor realised the blunder.

The healthy testicle was then frozen, while a plastic surgeon was rushed to the scene and tried to undo the damage.

He said: 'It seems I can no longer father children. I have gone through incredible stress and strain.'

The most common reason for payouts is when medics misdiagnose testicular torsion where the tubes inside the body get twisted cutting off the blood supply.

The condition has to be diagnosed quickly as the testicle can be dead within a few hours.

Other claims result from the consequences of hernia operations where the blood supply to the testicle is accidentally cut off in the surgery.

Joyce Robins, Co-Director of Patient Concern, said: 'It is beyond belief that medics could be so careless. No monetary amount could compensate for a life wrecked because a man can no longer father children.

'We would like to think that surgeons who make this such a crass error were barred from performing similar operations in the future - but we realise that is a vain hope.'

This aticle is courtesy from The Daily Mail.

NHS faces £24m bill after glue injected into girl's brain at Great Ormond Street

A simple mix-up in an operating theatre that left a "happy, active" 10-year-old girl with catastrophic brain damage has led to the NHS facing a £24m payout – the largest in a case of medical negligence.

Maisha Najeeb was keen on dancing and hoped to become a doctor when glue was accidentally injected into her brain during surgery at Great Ormond Street children's hospital in London in June 2010.

The accident occurred when a syringe containing glue was mistaken for one containing dye. Maisha, who is now 13, suffered what her lawyers describe as "catastrophic and permanent brain damage". She is in a wheelchair, can barely move, is blind in one eye, needs round the clock care and suffers from painful spasms in her legs.

In a settlement agreed at the high court in London, she will receive an initial £2.8m plus annual payments of £383,000 until she is 19. That will then rise to £423,000 a year until she dies.

If she lives until she is 64, as an expert hired by her family said they expected, then the NHS would have to eventually pay total damages of almost £24.2m.

"We are sad and devastated by what happened to our daughter. Her life is ruined. All her dreams have been broken," said Maisha's father, Sadir Hussain. He said he hoped that the family's legal action meant that "lessons will have been learned to avoid this happening to other families".

The hospital, which admitted liability, offered "unreserved apologies for the shortcomings in her care, the consequences of which have been tragic and devastating for Maisha and her family." It could not say if any member of staff had been disciplined over the incident. After an internal inquiry, the hospital has established an action plan of improvements, including the introduction of full colour-coding for all fluids and medications used in radiology procedures and, crucially, a new system of labelling syringes. Maisha's family had "engaged open-heartedly" with them and helped with that overhaul, said a hospital spokesperson.

The NHS Litigation Authority, which insures hospitals against lawsuits for medical negligence and acts on their behalf, will pay the agreed damages rather than Great Ormond Street itself.

Edwina Rawson, the family's solicitor at Field Fisher Waterhouse, said: "What is so heartbreaking about this case is that the injury was so avoidable.If the syringes had been marked up so the hospital could see which contained glue and which contained dye, then Maisha would not have suffered what is an utterly devastating brain injury. Such easily avoidable mistakes should not happen."

Before the blunder Maisha was a healthy 10-year-old, though she suffered from a rare condition called arterio-venous malformation (AVM), in which arteries and veins become tangled, which can lead to bleeding. Each time she suffered a bleed she went into Great Ormond Street for embolisation, in which glue is used to seal off the blood vessels that are bleeding and dye to highlight the blood flow.

The two sides could not agree on what impact the brain damage and AVM would have on Maisha's life expectancy. Her family said she could live until she was 64, but the hospital estimated that she could die of a bleed on her brain by 23.

Deborah Evans, chief executive of the Association of Personal Injury Laweyers, said the money would pay for the 24/7 care that Maisha will need forever. "While this is possibly the largest agreed payment we have seen, the amount is dependent on life expectancy and will never replace the life she would have led," Evans said.

This article is courtesy from The Guardian.

Major hospital blunders including 40 patients given surgery on wrong limb, revealed by official statistics

Almost 150 NHS patients have been harmed by incidents that should never happen, according to new figures - including the wrong patient receiving heart surgery, patients given overdoses and a woman who had her fallopian tube removed instead of her appendix.

Official statistics for a six month period show that the major blunders include 37 cases of patients who underwent surgery on the wrong part of the body.

In one case, the wrong patient was given a heart procedure.

One woman had the wrong fallopian tube removed during an ectopic pregnancy, probably rendering her infertile, and another had a fallopian tube removed instead of her appendix.

The wrong patient was given an invasive colonoscopy to check their bowel, while in four cases operations were carried out on the wrong teeth, and in other cases injections were given to the wrong eye.

In 69 cases, surgical instruments, needles swabs, specimen retrieval bags were left inside the body.

The figures disclose for the first time the number of incidents in each NHS hospital, and the types of blunders - some of which have either killed or seriously harmed patients.

In one incident, a drill guide block was left inside the patient’s body.

In another case, the patient died as a result of failure to monitor their oxygen levels, while one woman died from heavy bleeding following a planned Caesarean section.

Another had the wrong type of gas given, resulting in the patient’s death or severe harm, and one patient underwent surgery intended for someone else “due to incorrect results filed in notes”.

In total 21 patients were given the wrong implant or prosthesis. Seven patients were given the wrong dose of chemotherapy, resulting in harm, and five died or suffered severe harm after feeding tubes were inserted incorrectly by NHS staff.

In more than five cases, patients were given overdoses of drugs, with a weekly dose given in a single day.

Until now, only national totals were published.

The 148 incidents in six months suggests figures are “broadly comparable” to previous years, NHS England said, with 325 events in the previous 12 months.

Newcastle upon Tyne Hospitals NHS Foundation trust recorded the highest number of incidents - four in six months, with two patients “retaining foreign objects” one suffering wrong site surgery and one being given the wrong type of prosthesis or implant during surgery.

Nine more trusts recorded three incidents each during the period. They were The Royal Wolverhampton NHS trust, West Middlesex University NHS trust, South Tees Hospitals NHS Foundation trust, Sheffield Teaching Hospitals NHS trust, Leeds Teaching Hospitals NHS trust, Barts Health NHS trust, University Hospitals of Morecambe Bay NHS trust, Gloucestershire Hospitals NHS Foundation trust and Norfolk and Norwich University Hospitals NHS Foundation trust.

Dr Mike Durkin, National Director of Patient Safety at NHS England, said: “Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.

“Every single never event puts patients at risk of harm which is avoidable. People who suffer severe harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.”

Health Secretary Jeremy Hunt said: “We are determined to see the NHS become a world leader in patient safety - with a safety ethos and level of transparency that matches the airline industry.

“The publication of this data is a real step forward towards making this happen.”

This article is courtesy from The Telegraph.

Surgeon convicted of patient manslaughter through negligence

Surgeon David Sellu, who has been found guilty of manslaughter through gross negligence.

A consultant surgeon has been convicted of the manslaughter of a patient at a private London hospital and sentenced to two and a half years in prison.

David Sellu, 66, was found guilty of manslaughter through gross negligence over the death of James Hughes, who died three days after developing a life-threatening condition while undergoing treatment in 2010.

Hughes, 67, died at the Clementine Churchill Hospital in Harrow, north-west London, following knee replacement surgery. The operation went smoothly but while recovering from surgery he developed abdominal pain and was transferred to Sellu's care.

Sellu suspected there had been a rupture in the patient's bowel – a potentially life-threatening condition that requires surgery – but the surgeon ignored the urgency that the case demanded and the patient later died.

The judge at the Old Bailey, Mr Justice Nicol, said that Sellu had failed to give instructions to prescribe antibiotics and should have carried out and examined abdominal scans of Hughes far earlier.

In his sentencing remarks, the judge said: "Even if you had acted more speedily, there was a chance that Mr Hughes would have died anyway. There is always such a risk with major abdominal surgery of the kind he needed.

"But the chance would have been very, very much smaller if you had acted as a reasonable surgeon would have done on the Thursday night.

"The risks would have increased if the operation had not taken place until Friday morning and would have got progressively larger as the day went on, but at each stage the chances of his survival would still have been better than when he finally did get to the operating theatre late in the evening of Friday 12 February."

He added: "It was you who was responsible for determining his treatment. It is your several failures in that regard which amounted to gross negligence. I am afraid that it means your culpability is high. And that negligence contributed significantly to the death of Mr Hughes."

Elizabeth Joslin, a specialist lawyer for the Crown Prosecution Service, said: "James Joseph Hughes was in hospital for knee surgery when he by chance suffered a perforated bowel. David Sellu's care fell far below the expected standard, with terrible consequences.

"Prosecution of doctors for gross negligence manslaughter is rare and the threshold for criminal prosecution is high, but this doctor's actions were not mistakes or errors of judgment, but negligence so serious that he has now been convicted of a criminal offence. Our thoughts are with the family of Mr Hughes."

His wife, Ann, described the suffering experienced by the family in a victim impact statement put before the court. It said: "For three years we have struggled to discover and then accept the truth of what happened to Jim. The world does not stand still but for us we have been subjected to a tortuous purgatory that can only be brought to an end by truth and justice.

"Our trust in normal processes, authorities and structures of society was shattered by the inexplicable, callous and deceitful actions of the medical profession entrusted with the most basic responsibility to protect human life."

This article is courtesy from The Guardian.

Surgical Errors Can Cause Dramatic Health and Financial Consequences

Surgical errors are among the most costly medical negligence cases in terms of their impact on one’s health and financial consequences. Medical negligence can be defined as any type of physical or emotional harm that may occur as a result of misdiagnosis, incorrectly implemented medical procedures or failure to act on time when the situation requires emergency medical attention, among several other circumstances in which the medical staff is not performing on an adequate level. Individuals who suffered from physical pain, trauma, collateral medical conditions or emotional distress as a result of surgical errors are advised to partner with an experienced solicitor to take their case to court and obtain a solid compensation for the suffered consequences. A UK-based solicitor with a superb service record and a long list of satisfied clients is ready to evaluate any medical negligence case no matter the complexity and handle all the associated paperwork before and during court proceedings. 

Statistical Data Shows an Alarming Trend

Statistic data in the UK reveals a surprising negative trend. On average, about 11 serious surgical errors happen every single day in NHS-funded medical facilities. It is a very concerning number because most victims of such medical negligence cases don’t seek legal help to get compensations for their physical distress, emotional pain or medical conditions they developed as a result of the surgical mistake. The wisest thing to do in such a situation is to hire an experienced solicitor who possesses solid knowledge of all the legal intricacies and can navigate through the legal system to help the victim obtain financial compensation. 

Common Types of Surgical Errors

What type of surgical mistakes can occur during surgical interventions? Excessive bleeding as a result of incorrect administration of blood thinners or anticoagulants is a common medical mistake. The surgeon must accurately evaluate the patient before the surgery and make sure that he or she is not taking blood thinners, because they can cause dangerous bleeding accidents during the surgery, which are very difficult to stop.

Pieces of surgical material left accidentally inside the body of a patient is a very severe occurrence that often can cause dramatic medical problems if left uncorrected.

Failure to evaluate the eligibility of a patient for a particular surgery is also a common medical negligence issue. For example, individuals with severe heart failure, those who are susceptible to seizures or allergic to anesthetics may not be eligible for surgery, which is a circumstance that needs to be accurately evaluated prior to the surgery.

Victims of surgical errors are encouraged to seek the help of an experienced solicitor to discuss the opportunity of legal action.

Shocking hospital blunders that should NEVER happen

Medics have made dozens of serious mistakes when treating patients across Greater Manchester over the last 18 months.

The preventable errors – known as ‘never events’ because the Department of Health say they should not happen – include an operation on the wrong part of a spine and swabs left in women after childbirth.

Figures obtained by the M.E.N. show 28 patients have been ‘never event’ victims in the region in just 18 months.
Central Manchester Hospitals

There were seven incidents at the Central Manchester Hospitals – which includes St Mary’s, MRI and Manchester Children’s Hospital – in 2012/13 and three so far in the current financial year.

This year’s incidents included one where a wrong mole was removed from a patient’s face.

Swabs were also left inside two patients – one after an operation in the ear, nose and throat department and one in the obstetrics and gynaecology.
Salford

There were two ‘never events’ in Salford last year including one where two drill ‘guides’ were left in a patient and another where the ‘incorrect level’ of a person’s spine was operated on.

There have been a further two events this year.

Wigan

There were also two never events at the Wrightington, Wigan and Leigh Hospitals Trust in 2012/13 – root canal work on the wrong tooth and a swab left inside a patient’s knee.

Another took place this year where a patient received an overdose of a sedative.

The trust said that incident is under investigation and the patient has since recovered.

Royal Bolton Hospital

In two high-profile cases last year, swabs were left inside two women following childbirth at the Royal Bolton Hospital.

A third case of a swab being left inside a woman also happened last year. There has been one separate ‘never event’ at the hospital this year.
Pennine Acute Hospitals Trust

There were two never events at the Pennine Acute Hospitals Trust last year – where a ‘guide wire’ was left inside a patient after a line was fitted and where a swab was left in another patient. The trust runs North Manchester General Hospital, as well as hospitals in Bury, Rochdale and Oldham.
The Christie

An instrument was also left inside a patient at the Christie Hospital last year – the only never event to have taken place at the trust.

Stockport

There were two ‘never events’ at Stepping Hill Hospital in Stockport. A swab was left in a patient following a minor operation and the wrong strength of lens was used in an ophthalmology procedure.
Pennine Care

There was one ‘never event’ last year at Pennine Care, which provides a range of mental health and community services, when packing was left in a patient’s throat after a dental procedure.
Wythenshawe and Tameside

Wythenshawe and Tameside hospitals have had no ‘never events’ in the past 18 months.

Gill Edwards, a partner in the medical negligence department at law firm Pannone, who is also a former nurse, said: “These events should never happen.

“It’s important that hospitals learn from them to prevent them from happening again. It also important that patients are informed about what steps have been taken.”

NHS England is preparing its first set of quarterly lists of never events.

A spokeswoman said: “All never events require a robust investigation to identify why the failing has occurred and to ensure preventative measures are put in place to prevent re-occurrence.”

Have you been a victim of a ‘never event’? Call us on 0161 211 2323.
What the trusts say:

Central Manchester: All never events are pro-actively reported and investigated. Every never event is analysed and we are working hard to ensure similar events do not happen in the future. This work includes liaison with other hospitals to ensure learning across the NHS.

Salford Royal: We have investigated the circumstances around these never events and have made changes to our practices and procedures. Both of the patients received an immediate apology.

Stepping Hill: A full investigation was immediately launched after both events. As in any situation when an error occurs, additional levels of safeguards and checks were put in place which are above and beyond the standard procedures.

The Christie: The instrument was very small and the incident was graded as a '2' (minor) because the patient made a full recovery without adverse impact and went home on the expected day of discharge.

Royal Bolton: Our process for using and retrieving swabs has been thoroughly reviewed and changes made to theatre processes to make it more effective. New swab trays have been introduced... which make it easier to count swabs as they are retrieved.

Pennine Acute: Both events were fully investigated and the findings subjected to a high-level review. A number of changes had been made relating to retained swabs and instruments.

This article is courtesy from Manchester Evening News.

Mystery object accidentally left inside surgery patient

A foreign object was accidentally left inside a patient during a surgical procedure by the Epsom and St Helier Trust.

The trust would not reveal which hospital the serious event occurred in or what the object was; despite doing so when reporting “never events”, incidents so serious they should never happen, in the past.

However, it is understood this never event occurred under local anaesthetic in one of the maternity departments in May this year. The patient was informed and received an apology.

After an initial review a serious incident investigation was launched which identified a failure of staff to follow trust policy. Following this the chief executive, Matthew Hopkins, apologised to the patient for the failure.

A spokesperson for the Epsom and St Helier Trust said: “We are absolutely committed to providing our patients with a high level of compassionate care, and the health and wellbeing of the people we treat is at the heart of all we do.

“As such, any incident that may impact on the health or safety of our patients – however rare – is taken very seriously indeed.

“In May of this year, we reported one ‘never event’, when a foreign object was retained following a surgical procedure.

“It’s important to note that incidents such as these are rare. In the last financial year, we treated more than 800,000 patients and reported one ‘never event’.

"Whilst we recognise that this is a very small proportion of the total patients treated, we will not hesitate to act upon and learn from these incidents.

“As with any untoward incident, we launched a thorough internal investigation into this matter, and as a priority, actions and measures were put in place to help prevent a similar event occurring.”

This article is courtesy from Your Local Guardian.