Serious mistakes made in surgery at the Countess of Chester Hospital

Reporter:

Steve Creswell

MEDICAL staff at the Countess of Chester Hospital made five serious mistakes during surgical procedures last year, it has emerged.

The annual report by the NHS trust which runs the hospital outlines details of the so-called ‘never events’ in 2016-17.

The incidents have led the trust to establish a Theatre Safety and Quality Group to “review cultures and behaviours within theatres”.

An investigation by the Leader revealed there had been eight ‘never events’ over the course of the previous five years, from 2011-12 to 2015-16.

A ‘never event’ is defined as a “serious, largely preventable patient safety incident that should not occur if the preventative measures have been implemented”.

They include instances of ‘wrong site surgery’, where a procedure has been carried out on the wrong part of the body, and items such as swabs being left inside a patient after an operation.

Hospital chiefs have previously said that far from being less safe, the NHS has never been more focused on patient safety than it is now.

But public sector workers’ union UNISON has suggested soaring pressures on medical staff due to Government-imposed cuts to the NHS could explain the apparent increase in mistakes.

The five incidents listed in the Countess of Hospital NHS Foundation Trust’s report are:

l Wrong site block – super- clavicular nerve block (a nerve block is a form of anaesthetic)

l Incorrect swab count – breast surgery

l Anaesthetics – wrong site transverse abdominis plane;

l Wrong site block – finger

l Retained swab – vascular surgery.

Hospital chiefs stress all ‘never events’ are thoroughly investigated and a culture of transparency and honesty means staff are not fearful of reporting issues so lessons can be learnt.

The annual report states: “All five ‘never events’ were subject to a robust investigation with an action plan to address any issues identified.

“To ensure learning and improvements from these events are undertaken, a Theatre Safety and Quality Group has been established to review cultures and behaviours within theatres, with future plans to develop an enhanced training plan which will be extended to mandatory training and induction.”

The report revealed there had been 66 serious incidents in 2016-17, compared to 41 in 2015-16.

These included one ‘alleged or actual abuse of adult patient by staff’, 10 maternity or obstetric incidents, 15 slips trips and falls, and 11 surgical or invasive procedure incidents.

There were 18 serious incidents requiring investigations involving personal data, potentially affecting around 1,000 people.

One related to unauthorised access by a staff member who was subsequently disciplined, while another was a technical security failure by a third party contractor.

The Leader’s previous investigation revealed there had been two ‘never events’ in 2015-16, two in 2014-15, three in 2012-13, and one in 2011-12.

UNISON said: “With NHS staff facing higher workloads, working through their breaks and beyond their shifts, a possible consequence is that mistakes are more likely.

“Like all NHS hospitals, the Countess is under increasing pressure to meet rising demand with dwindling resources.

“Despite the best efforts of staff, inadequate funding provided by Government is becoming increasingly evident in greater pressures on hospital wards, longer waiting lists for operations and longer ambulance response times.”

Ian Harvey, the trust’s medical director, said: “These are serious incidents that should never happen. We do everything we can to learn from each one and minimise the risk of them happening again and we are encouraging our staff to speak out safely.

“This could account for the apparent increased numbers reported this year, but we’ll never be complacent about patient safety.

“We will always strive to provide the best care.”

Email:

steve.creswell@nwn.co.uk

See full story in the Chester Leader

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