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Hospital bosses sorry after swab left inside second East Lancs patient
HOSPITAL bosses have again pledged to ‘learn lessons’ after it emerged a second patient had a swab left inside their body after surgery.
The latest blunder happened at the Royal Blackburn Hospital and resulted in the patient undergoing a further operation to retrieve the swab.
The incident was listed in newly-published NHS papers and has been classed as a ‘never event’, which is an incident deemed so serious that it should never happen in the NHS.
East Lancashire Hospitals NHS Trust (ELHT) said the swab was removed in the same theatre session and the patient was not harmed, but said it could not release further details due to strict rules around patient confidentiality. The incident happened in March.
The Royal College of Surgeons said the error was ‘extremely serious and completely unacceptable’, due to the risk of infections and the need for further surgery.
It comes after a swab was left inside a woman in the maternity department at Burnley General Hospital, also run by ELHT, in July last year.
Russ McLean, chairman of the Pennine Lancashire Patient Voices Group, said: “I’m appalled to hear of this latest incident and quite frankly I am worried too.
“There was a similar incident last year and the trust assured us that lessons would be learned and processes would be put in place to ensure that this kind of thing would not happen again.
“For goodness sake ELHT, for the sake of your patients and the future of our hospitals, please get your act together.”
Surgical swabs, which are wads of absorbent material, are routinely used to contain bleeding in surgery, and careful steps should always be taken to make sure they are removed.
News of the incident comes as the Care Quality Commission (CQC) prepares to publish a crucial inspection report on ELHT this week, which bosses hope will persuade the NHS to lift the trust out of ‘special measures’.
Last year’s incident in Burnley was initially classed as a never event, but has since been downgraded to a ‘serious’ incident, as it did not require another procedure.
The patient, a 25-year-old mum from Blackburn, spoke to the Lancashire Telegraph earlier this year, claiming the swab had been left inside her for about two weeks and left her ‘screaming in pain’.
She returned to the hospital after her mother advised her the level of pain and swelling was abnormal, and the swab was removed without surgery.
An investigation resulted in a new system where all surgical patients in obstetrics and gynaecology now have a purple wristband placed on them for each swab, or surgical pack inserted.
The bands act as a ‘visual reminder’ to clinicians that items still need to be removed once bleeding has stopped.
The wristband system was thought to be impractical for other divisions, however, as many more swabs are generally inserted than in obstetrics and gynaecology, where only a few might be used.
Never events frequently result in a compensation bid from the patient or their family, but ELHT refused to say whether a claim had been made.
Dr Ian Stanley, acting medical director at ELHT, said: “The situation in March is very different from the incident (last) summer, but the lesson we have learned is around ensuring that there is an individual responsible for confirming that a swab count is correct.
“On this occasion there was miscommunication between staff, and the patient was woken up when the swab count had not been confirmed as correct.”
“Quality and safety remain our main priority and it’s always a concern when we don’t meet these high standards. On both occasions we have been open and honest with the patient and a full apology given.”
He said the decision to downgrade the seriousness of the incident last summer had been confirmed by commissioners and NHS England.
The trust performs more than 33,000 operations each year, he added.
A spokesman for The Royal College of Surgeons said: “Leaving swabs, or any foreign object behind after surgery, is extremely serious because of the risk of infections and the need for further surgery.
“Never events are incidents that are completely unacceptable. However rare they are, never should mean never.
“Educating the entire surgical team is fundamental to learning about and preventing never events. The pre and post operative check lists should involve all theatre staff and are designed to prevent events.”
Blackburn MP Jack Straw said: “Any incident like this is serious but extremely rare. There’s a new chief executive coming into the trust and I feel more confident about the future.”
There were 312 never events across the whole of the NHS in 2013/14, according to NHS figures.