Hospital probe after ‘alarming’ incident saw patient almost given surgery on wrong part of body

Medical staff were poised to start surgery when it was highlighted that there had been an error in preparation and “wrong site surgery” was about to take place.

A probe was launched after the blunder, referred to in a report by North Tees and Hartlepool NHS Foundation Trust as a “Never Event”.

A trust board meeting heard the patient was not harmed as the error was spotted in time, but a full investigation was launched and procedures have been changed as a result.

The patient concerned was made aware of the blunder, but Trust bosses could not divulge any more details – including the procedure, who was involved, or at which site the error had taken place – because of patient confidentiality regulations.

Councillor Stephen Akers-Belcher, chairman of Hartlepool Borough Council’s audit and governance committee, which includes health and scrutiny, described the incident as “alarming”.

The Trust said it was the first “Never Event” in almost two years after the last one was reported from June 2012.

Never Events are described as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been put in place.

A report to the meeting, held last week at the University Hospital of Hartlepool, said: “During the reporting period of April 1, 2013 to March 25, 2014, North Tees and Hartlepool NHS Foundation Trust have had one Never Event relating to wrong site surgery. This occurred on February 4, 2014.

“This is subject to reporting to the commissioners and has been investigated in line with trust policy and learning has been disseminated throughout the trust.

“Prior to this event, the previous Never Event occurred on June 7, 2012.”

But Cath Siddle, the Trust’s director of nursing, patient safety and quality, said: “There was no harm to the patient in the wrong-site surgery,

“It didn’t go to full procedure and there was absolutely no harm for the patient.

“However, in the criteria for Never Events, it needs to be reported.”

Trust chairman Paul Garvin added: “For the first time in about two years we had one Never Event, but there was no harm.”

Hartlepool and Stockton Clinical Commissioning Group (CCG), as commissioners, said the Trust do report incidents to them as a matter of course.

Coun Akers-Belcher said: “Obviously it’s alarming and I will be referring the matter to the Health and Scrutiny committee to get a local response.

“We need to question this, and we need to be reassured about safeguards.”

He added: “I think the Trust needs to get its priorities right and need to have a lot more focus on patient care and quality of care.

“My concerns are with the senior managers of the Trust. The staff do a fantastic job, but it seems to be an ongoing concern about quality and safety and this has confirmed it.

“I would like them to come to a Health Scrutiny forum.”

North Tees and Hartlepool NHS Foundation Trust medical director David Emerton said: “We have an open culture of reporting incidents at the Trust.

“All incidents are reported, investigated and lessons are shared and learned irrespective of their seriousness.

“We do all we can to avoid any incidents, including the Never Events, occurring.

“Should there be an incident we are open with the patient concerned, regardless of whether or not they have been caused any harm.”

The Mail reported earlier this month that the Trust forked out £8.9m for medical blunders in 2012-13, according to the NHS Litigation Authority.

But Trust chiefs said at the time that the figures can be “skewed” as some payments can relate to historical cases prior to 2012-13 and the payment system has changed to speed up the process.

l DO you know who the patient was who nearly had surgery on the wrong part of their body? Contact the newsdesk on (01429) 239380.