“Daily Mail special report shows nightmare scenarios frequently happening”
“They occur at least five times a week in NHS hospitals across Britain”
“The most recent data from NHS England show that, in the past four years, nearly 1,200 patients in England have been the victims of such incidents”
“Leaving hospital after prostate cancer surgery, Frank Hibbard and his family felt a sense of relief that the worst was behind him. “
“Frank, then 56, had been told the operation should rid him of the cancer, which was contained within the prostate gland.”
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However, “surgeons had accidentally left an 8 cm-long piece of gauze inside his pelvis. It led to a type of soft tissue cancer called angiosarcoma that was so advanced by the time it was diagnosed in March 2014, nothing could be done.”
“Frank died two years ago at the age of just 69.”
“If this was an isolated case, it might be easy to dismiss it as a tragic, but rare error. But these kinds of serious medical blunders […] occur on average at least five times a week in NHS hospitals across Britain.”
“The most recent data from NHS England show that, in the past four years, nearly 1,200 patients in England have been the victims of such incidents.”
“The most serious include a man who needed a cyst removed, but woke up to find surgeons had instead cut off a testicle, and a woman with a diseased ovary who lost a healthy kidney instead because blundering surgeons had not read her notes properly.”
“Other calamities included the wrong implants being used, doctors over-prescribing powerful drugs and frail hospital patients falling out of poorly secured windows.”
“But it’s cases of surgical equipment being left inside patients that may cause most alarm — not least because they seem avoidable. In Frank’s case, the hospital didn’t just leave the swab inside him — they also missed repeated chances to spot their mistake.”
“Twice in the following few years after his surgery Frank had scans — the first in 2003 before radiotherapy to treat a return of his cancer and then in 2004 when he needed hernia surgery.”
“Both times doctors failed to detect the melon-sized mass that had formed next to his rectum as scar tissue formed round the swab, despite the mass being visible on his CT scan.”
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“Finally, after a CT scan in March 2014, doctors realised he had an enormous mass in his abdomen. The plan was to remove it but in the following weeks Frank developed severe rectal bleeding […] and his health deteriorated rapidly.”
“Tests revealed he had advanced angiosarcoma, a fast-growing and aggressive cancer in the inner lining of the blood vessels. Within four months, Frank, a grandfather of six, had died.”
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“The coroner’s report concluded the swab ‘materially contributed’ to the development of the cancer: ‘Several agents are known to predispose formation of angiosarcoma including a surgical sponge or gauze retained for a prolonged period in a body cavity’.”
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“Around a third of ‘never events’ [serious medical blunders] occur when doctors and theatre nurses leave swabs, sponges or even surgical instruments inside patients during operations — drill bits, scalpel blades, needles and scissors have been discovered months, or even years, later.”
“Never events are not a new phenomenon and there have been concerted efforts to tackle the problem.”
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“Last year, the Organisation for Economic Co-operation and Development reported that Britain has one of the highest reported levels in the industrialised world for leaving surgical items inside patients.”
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“But the charity Action Against Medical Accidents says there’s little sign of progress. ‘There is no good evidence of a dramatic improvement and it is really concerning that there has not been a discernible drop in these incidents,’ says Peter Walsh, the charity’s chief executive.”
“Furthermore, he adds, ‘the NHS has been saying for years there is massive under-reporting of them.’”
“‘Every single one is avoidable and we want to know what’s going to be done about those hospitals that are not reporting them.’”
“The key to preventing such never events is using a surgical checklist …”
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“‘Whether you’re a surgeon in London or Devon, the way you work and use a surgical safety checklist should be the same,’ he says.”
“‘At the moment, there is a marked variation and it’s a big problem.’”
“For example, surgeons are meant to visit each patient before operating on them and personally mark the surgical site using a specially provided marker pen containing ink that cannot be rubbed off easily.”
“But research by the CHFG suggests that in some busy theatres, ordinary biros (ink pens) are used if the marker can’t be found. This can rub off, paving the way for wrong site surgery.”
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“Leslie Hamilton, a retired cardiothoracic surgeon and a spokesman, explains: ‘Mistakes happen — it’s human nature. But if the proper checks are done these events are preventable.’”
“But as Frank Hibbard’s case shows, this system is not foolproof. ‘It should be a simple case of counting swabs in and out again,’ says Renu Daly, a medical negligence specialist at Hudgell Solicitors acting on the family’s behalf. Luton and Dunstable Hospital told Good Health it was one of the first hospitals in Britain to use the checklist.”
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“The number of never events may be far higher than reported as some serious incidents are recorded differently. “
“Elise Cattle, 27, a part-time nursery nurse from Hull, suffered five months of pain and infections before discovering it was due to gauze left in her after the birth of her son Freddie in August 2012 at Hull’s Women and Children’s Hospital.”
“She’d torn badly during the birth and bled heavily — midwives used packing to stem the flow, but later failed to remove it all.”
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“The experience has had a lasting effect on Elaine. ‘I would like more children, but I still feel mentally scarred by what I’ve gone through,’ she says.”
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GOING UNDER THE KNIFE? HOW TO PROTECT YOURSELF…
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Wednesday, Jun 22nd 2016