Royal Preston Hospital blighted by errors that should '˜never have happened' to patients
Three medical errors so serious they should never happen were recorded at Royal Preston Hospital last year, it can today be revealed.
The ‘never events’ included surgery carried out on the wrong body part and a stomach tube being misplaced.
The major blunders, which all happened between April and the end of December, leads to calls for greater transparency and for the NHS to learn from its mistakes.
Chorley MP Lindsay Hoyle said: “I’m very concerned the information has not been given as to how serious these mistakes were.
“We are not asking for names, but we want to know what has gone wrong.
“There’s a lack of transparency again.”
The errors involved two ‘wrong site surgeries’ – operations carried out on an incorrect body part – and a tube running from the nose into the stomach being misplaced, it was revealed following a request under Freedom of Information laws.
The same request also revealed that there were five ‘never events’ at Blackpool Victoria Hospital, which included the wrong lens being implanted in a patient’s eye on three occasions in just one month.
The major blunders, which all happened between April and the end of December, led to calls for the NHS to ‘learn from mistakes’ and to ensure future mistakes are avoided.
Estephanie Dunn, regional director for the Royal College of Nursing (RCN) in the North West added: “Healthcare employers, frontline staff and patients are naturally concerned about all so called ‘never events’ or medical mistakes so serious they should never happen.
“Although never events are rare, just one ‘never event’ is one too many and can have a devastating and lasting effect on a patient and their family.
“The NHS needs to learn from mistakes and ensure that the appropriate action is taken to prevent similar incidents from being repeated.
“The NHS is also facing a period of unprecedented pressure with ever increasing demand from an ageing population with complex needs.
“Therefore it must tackle the current nursing and workforce crisis and insufficient social care provision to ensure that there are the appropriate number of nurses with the right skill mix to ensure safe, quality care for patients.”
Figures show there were more than 300 ‘never events’ across the country between April and December last year.
Elaine Thomas, from Lancaster, whose mother Doreen Buckley was given an ‘unnecessary’ emergency chest drain by an agency doctor at Blackpool Victoria Hospital in 2015, said: “Is this NHS that we love under such terrific strain that these events are happening, or is it down to the competency of the doctors?
“It’s extremely disappointing this is continuing to happen and I’m just frustrated that it is.”
Chorley MP Lindsey Hoyle said he was “concerned” by the findings, adding that NHS staff are “over-worked and overwhelmed”.
A spokesman for Lancashire Teaching Hospitals Trust, which operates Royal Preston and Chorley hospitals, said it couldn’t elaborate on what the ‘wrong site surgeries’ involved due to ‘patient confidentiality’, but said apologies had been offered to those affected.
Around 88,000 operations were carried out last year, up 10,374 from the year before.
In a statement, chief executive Karen Partington said: “Patient safety is our top priority and we are very open with patients and their families on the rare occasions when things go wrong, both in terms of apologising and sharing learning.
“We take all precautions possible to minimise risk, and we investigate all never events and ensure any necessary action and improvements are implemented. We work with patients affected by never events to resolve any issues; lessons have been learned and robust measures have been put in place in a bid to avoid any repeat incidents.
“We are actively taking part in national patient safety initiatives, being led by consultants and senior nurses, to ensure we are adopting best practice in the area of patient safety.
“We conduct periodic checks and audits to verify that changes have been embedded, and also invite external experts to review our processes and practice to provide independent assurance that services are safe.”
Why ‘never’ is merely a theoretical concept
WHAT IS A NEVER EVENT?
A never event is described by NHS England as a ‘serious incident that is wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers’.
“Each never event has the potential to cause serious patient harm or death,” it said. “However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event.”
HOW MANY NEVER EVENTS HAVE HAPPENED IN PREVIOUS YEARS?
In 2013/14, four never events were reported, followed by three the year after, government statistics showed.
There were three events in 2015/16, which were blamed on two ‘wrong site surgeries’ and one ‘wrong implant or prosthesis’.
The overlap could mean some of those were also recorded in the 2016 figures, though one is thought to involved Chorley woman Margaret Draper, 81, who allegedly had four surgical swabs left inside her for two weeks in August 2015.
Medical negligence lawyers alleged Margaret suffered two weeks of pain after a pacemaker operation in Preston and were reported to have launched a claim against the trust, which apologised and said lessons had been learnt.
IS A COMPARISON POSSIBLE?
The NHS moved the goalposts when it comes to recording never events relatively recently, and said the definition now includes incidents that have the potential for serious harm or death, rather than actual harm as was previously the case.
Therefore, it said ‘it is not possible to compare the number of never events reported’ in 2015/16.
“The NHS has become better at incident reporting which is also expected to have led to an increase in the numbers of reported never events,” it said.
It is possible however to compare last year’s figures against others trusts. The worst was Barts Health NHS Trust, which had 10. Nearby Blackpool was joint fourth in England with five recorded never events.
‘Hospital trust has lack of transparency’
Chorley MP Lindsay Hoyle asked why Blackpool Victoria Hospital was able to give details of its ‘wrong site surgery’ last year – it was a mole being incorrectly removed – but Lancashire Teaching Hospitals Trust said it wasn’t, citing ‘patient confidentiality’.
He said: “I’m very concerned the information has not been given as to how serious these mistakes were. We are not asking for names, but we want to know what has gone wrong.
“There’s a lack of transparency again.”
He added: “I do recognise we are lucky we have got exceptionally good staff in the NHS. They are over-worked and over-whelmed.”
Katherine Murphy, chief executive of the Patients Association, said she was concerned after national figures showed 314 never events were recorded between April 16 and December 31 last year.
She said: “Never-events are precisely that, events that should never, ever happen.
“The fact that they are occurring should ring alarm bells in trusts, with Clinical Commissioning Groups (CCGs), NHS England and the Department of Health.
“There are no excuses for failing to follow medical protocols as it could be the difference between life and death.
“Whilst patients and the public understand that medical professionals and support staff are under pressure and have increasing workloads, this is not an excuse for allowing never-events to occur.
“Ultimately, most patients will be anxious or at any rate, unwell, and so they should not have to have the added stress and burden of worrying about issues like never-events.”
Dr Mike Durkin, NHS National Director of Patient Safety, added: “All patients deserve high quality, safe care. We expect organisations to investigate and learn from mistakes, and the fact that more and more NHS staff take the time to report incidents is good evidence that this learning is happening locally.”
Mark Hendrick, MP for Preston, was not available to make a comment.
Swabs left inside patient after operation
In January this year, it was revealed that medics at Blackpool Victoria Hospital found four swabs accidentally left inside an elderly patient, following mistakes made at Royal Preston Hospital.
Margaret Draper, 81, was left with four large surgical swabs inside her for two weeks after failings during her permanent pacemaker surgery at RPH.
Margaret was later moved to Blackpool Victoria Hospital, but her solicitors say there was an insufficient verbal handover by the staff in Preston, meaning the Vic medics were unaware of the surgical swabs left inside the wound.
Over the next week, as Margaret’s condition did not improve, the decision was made to remove the pacemaker on August 27, 2016.
It was only when this procedure was carried out that the staff at the Vic became aware of the swabs still inside her.
Margaret, from Chorley, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate and Lancashire Teaching Hospitals Trust has now admitted liability.
Speaking in January, Margaret said: “Since the initial surgery, I’ve suffered with an ongoing infection and had to undergo further surgery to have the pacemaker relocated.
“As well as the physical pain and scars that I’ve been left with, my experiences have had a huge impact on me mentally and the support from my family has really helped me to get through the drawn out and stressful complaint procedure.”