Leicester Health Chiefs In Operations Probe

Two “Largely Preventable” Surgical Incidents Under Investigation

10.02.2015

Two “serious, largely preventable” incidents that occurred during operations are being investigated by health managers at Leicester hospitals, it has been revealed.

The first incident occurred at Leicester General Hospital in December. A patient who had undergone hip surgery required a further operation after it was discovered that a wrongly-sized femoral head or ball joint had been fitted.

The second incident, also in December, took place at Melton Hospital. A woman due to have her third toe straightened instead received surgery to her second toe.

In the case of the former incident, the incorrectly-sized replacement joint was discovered when the patient continued to experience problems following the original operation. 

In the latter, a surgeon identified a more pressing need for surgery on the patient’s second toe. The patient has since had surgery on the third toe and is reportedly ‘pleased’ with the outcome.

Both incidents have been classified as “never events”, which the Department of Health describes as a “serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented”. 

Despite both incidents being resolved, Moira Durbridge, Director of Safety and Risk at Leicester’s hospitals, said: “We would rather err on the side of caution and carry out an investigation to see if there is any learning from an incident.”
 

Expert Opinion
Never events should be just that – events that simply do not happen and it is imperative that Trusts across the UK invest in training to ensure every step is taken to protect patients and prevent injury where at all possible.

“Following the occurrence of a ‘Never Event’, each Trust should undertake a root cause analysis report to get to the bottom of exactly how and why something could go so seriously wrong and it is encouraging that these guidelines are being put into place.

“Many of our clients contact us as they are frustrated at the lack of information that they have been given about why there were errors in their care. Each Trust must provide clear, transparent information to patients who have fallen victim to a Never Event to help them come to terms with their ordeal and provide reassurance that steps have been taken to improve patient safety in future.”
Julianne Moore, Partner