NHS Foundation Trust Accepts Responsibility For Never Event – something which it admits should not be allowed to happen

An 81-year-old woman from Chorley was left with four large surgical swabs inside her for two weeks after failings during her permanent pacemaker surgery at Royal Preston Hospital (RPH) – the incident is on the list of NHS never events, something the organisation says should simply not be allowed to happen. 

Margaret Draper, who was 79 when she underwent the operation on 13th August last year, suffered excessive bleeding during the procedure, which required intervention from the surgical team to help control the bleeding.  

An NHS investigation has found that due to insufficient training of the surgical team at the Hospital, the wrong type of surgical swabs were used during the procedure to help stem the bleeding. Further to this, the surgical team opted to leave the swabs in to help control the bleeding post-surgery, still unaware of their error. 

Margaret was then moved to Blackpool Victoria Hospital (BVH), however due to an insufficient verbal handover by the staff at RPH, BVH were unaware of the surgical swabs that had been left inside the wound.

Over the next week as Margaret’s condition did not improve, the decision was made to remove the pacemaker on the 27th August. It was only when this procedure was carried out that the staff at BVH became aware of the swabs still inside Margaret.

Margaret instructed specialist medical negligence lawyers at Irwin Mitchell to investigate and the Trust has now admitted liability for the Never Event but the way the NHS has handled the issue has raised concerns amongst her family that lessons may not be learned. An initial investigation found that the mistake did not constitute a Never Event before further reviews following pressure from the family found that it did.

Never events are defined by the NHS as serious incidents, which ultimately are wholly preventable, due to the guidance and safety recommendations available at a national level that act as protection against a never event happening. The NHS has a list of 14 Never Events which it says should not be allowed to happen at all.

The initial investigation into Margaret’s care carried out by the NHS completed in December 2015 and found that the incident did not constitute a ‘never event’ due to the Consultant who led the initial procedure asserting that the product used was a Surgicel product, a hemostatic agent or blood-clot-inducing material, and was intentionally left in the wound to act as a haemostat.

Due to pressure from Margaret’s family, the surgical swabs were sent for evaluation and in March this year a report found that they were not the Surigcel product the surgical team had insisted they were, and instead were surgical swabs, therefore constituting a ‘never event.’

In the months following this finding, Margaret’s family have held numerous meetings with senior managers at the Lancashire Teaching Hospitals NHS Foundation Trust, to ensure some accountability on behalf of Margaret.

Shahin Master, an expert medical negligence lawyer at Irwin Mitchell’s Manchester office, said: 

Expert Opinion

“These kinds of incidents are on the NHS never events list because they just simply should not happen.

“While the Trust has now, over a year since the initial operation, admitted to Margaret and her family the failings during the initial operation and subsequent care, Margaret is still understandably extremely upset due to the continued health issues these failings have caused.

“It is imperative that every time a never event occurs it is thoroughly investigated and that information shared across the NHS so that they can eliminate these incidents once and for all.”
Shahin Master - Senior Associate

Margaret said: “The last 15 months have been a difficult time for me and my family as a result of the failures by staff at the Royal Preston Hospital. 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.

“It worries me that the initial NHS investigation did not find that this was a Never Event and that it was only after we continued to force the issues that the true scale of the problem was revealed.”

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