Nurse Left With Seven-Inch Forceps Inside Her Wins Battle For Justice

Expert Lawyer Calls For Improvements After Hospital Error Is On NHS List Of ‘Never Events’ That Are Unacceptable

09.05.2013

By Helen MacGregor

A mum-of-four left with seven-inch forceps inside her for three months following an operation to remove her gallbladder has joined calls from specialist medical law experts at Irwin Mitchell for hospital trusts to improve staff training to put an end to ‘never events’ - basic preventable mistakes.

The ‘unacceptable’ error during key-hole surgery carried out at the Alexandra Hospital in Worcestershire in February 2009 left Donna Bowett sick from excruciating pain and losing weight for three months because no one could explain her symptoms.

The former nurse was referred for an MRI scan but this had to be aborted when she was screaming in pain due to the magnetic force from the machine pulling on the metal forceps inside her, but doctors still didn’t spot the error.  

The blunder was eventually picked up on x-ray at A&E later that day and horrified doctors, who initially thought the forceps must have been in her nurse uniform pocket rather than inside her, sent her for emergency surgery to remove them.

Donna, 42, still suffers daily from the damage caused by the forceps with constant abdominal pains requiring daily high dose pain killers and altered bowel habits. She also suffers with depression and nightmares and has been forced to step down from being a ward nurse and now works for the NHS in an admin role.

She contacted medical law experts at Irwin Mitchell in a battle for justice against Worcestershire Acute Hospitals NHS Trust who admitted they were at fault for the error and have agreed a six-figure sum in an out-of-court settlement to fund the ongoing care and rehabilitation services Donna needs and to cover her loss of earnings.

However, Donna, from Kidderminster remains concerned that no explanation has ever been provided as to why the surgeon used such large forceps during her key-hole operation, which are usually only used in open surgery. The Trust have been unable to provide an explanation and the surgeon has since left the hospital leaving Donna concerned without any answers about what actually happened during her surgery that day.

‘Retained foreign object post-operation’ is one of a number of errors on a special NHS list of ‘never events’ - problems which the NHS says are simply “unacceptable and eminently preventable”. All medical instruments should be counted in and out of a patient during a procedure and checked by two members of hospital staff as a failsafe.

Lindsay Tomlinson, a medical law expert from Irwin Mitchell who successfully represented Donna in her claim against the NHS Trust, said: “This is a devastating case that shows the lasting damage which simple avoidable errors can cause. For medical forceps to be left inside Ms Bowett for three months is completely unacceptable.

“This constitutes a ‘never event’ according to the NHS’ own Patient Safety Guidelines which recognises that such occurrences are unacceptable and completely preventable if the appropriate procedures have been implemented.

“Never events should be just that, events which just do not happen, and it is imperative that trusts across the entire country invest in training to ensure every step is taken to protect the safety of patients and prevent injury where at all possible.

“It is also very worrying that the forceps were used in the key-hole gallbladder operation in the first instance as they are not usually required, and we still have no answer from the trust as to why they had been used.

“Sadly the medical law team at Irwin Mitchell have seen a number of repeat incidents of retained instruments and swabs despite these having been classed as ‘never events’ by the NHS some years ago. Staff must be better trained to use the correct equipment and follow strict measures to make sure there is no chance any foreign objects can be left inside patients.”

Donna said: “I couldn’t believe the pain of the MRI scan. Doctors asked if I had any metal on me or in my body as the scanner uses magnets, but because I was completely unaware I said no. In reality the magnets were moving the forceps inside me and trying to pull them through my skin.

“They were unable to finish the scan because I was in so much pain and I was sent for an x-ray instead. I remember the nurse saying, ‘don’t worry Donna, the days of them leaving instruments inside patients are long gone’. It had never even crossed my mind.”

Donna added: “When they found out it was forceps inside me I was told there was a risk the forceps could have damaged my bowel which is life threatening and that I might not pull through the operation. I just could not believe what was happening to me.

“They found an abscess in my stomach and I stayed in hospital for five days while it was treated. I was then discharged and told to go back if the pain worsened.”

Three years on from the operation, Donna still suffers pain on a daily basis, is unable to lift heavy objects or exercise and has to restrict her diet due to bowel problems. She is physically and mentally scarred by what happened and fears she may still die as a result of what happened.

She said: “I am not the person I used to be because of what happened and have become withdrawn and very depressed. I feel very aware of my own mortality. My youngest two children are still 14 and 15 so it’s been very hard on them to see their mum suffer.

“I am devastated that such a thing could happen. There is no excuse for it and I hope improvements are made and staff are trained to ensure nothing like this can happen to anyone else. I’m grateful I am now able to fund the therapy, medication and treatment I need but I still have questions as to why it happened in the first place.”

Lindsay Tomlinson added: “Clearly there was a basic failure to care for Donna properly during her treatment.  

“She has been left traumatised by what happened and is now at a greater risk of developing problems in the future, including a risk of bowel obstructions.”

In January 2011, the Department of Health extended its list of ‘never events’ to include 25 serious, preventable patient safety incidents that should never occur whilst in the care of the NHS.  In January 2012, the list of 25 never events was retained with minor amendments to some definitions.

The list in 2011 added tragedies such as maladministration of insulin, falling from unrestricted windows and severe scalding to those already identified on the original list of eight published in April 2009, including medical instruments and swabs being left inside patient’s bodies, and operations being carried out on the wrong body part.

Read more about Irwin Mitchell’s expertise relating to surgery claims