NHS watchdog orders crackdown on basic safety checks by surgeons

Trust faces prosecution after series of preventable errors in operating theatres, including surgery on the wrong body part and swabs being left inside patients

The cases of six patients who were the victims of serious errors at a major teaching hospital are to be used to spotlight the dangers posed across the NHS by surgeons who fail to make basic checks before operating.

In an unprecedented move, the Care Quality Commission, the NHS regulator, last week threatened to prosecute Plymouth Hospitals NHS Trust unless it made immediate improvements. Of the six incidents, four involved surgical swabs left inside patients, one patient had an operation on the wrong part of the body and another had an anaesthetic in the wrong place.

They are among 111 so-called "never events" that occurred across the NHS last year. Never events are defined as incidents that should never happen because they are dangerous and easily avoided.

Next month the CQC will publish the result of its Plymouth investigation, which will carry a warning to other trusts to tighten implementation of the surgical checklist introduced in February 2010. It is the first time the CQC has publicly reprimanded a trust and demanded improvements before publication of its report.

A CQC spokesman said: "We are saying: this is a problem now and you need to fix it immediately. We wanted to speed things up, so we came out with what we had got."

The Department of Health published a list of eight never events last year, with a warning to trusts that they would not be paid when they occurred. Despite this, more than two never events a week were recorded in NHS hospitals in England last year. Over half were related to surgery on the wrong site and a third involved feeding tubes being wrongly inserted into the lungs instead of the stomach.

The average cost of dealing with each error was £35,000, adding up to £3.9m for the 111 never events. The Secretary of State for Health, Andrew Lansley, last week announced a trebling of the never events list, with financial penalties for trusts. "We have identified 25 preventable incidents – 'never events' – which should never happen in a high-quality healthcare service and for which payment can be withheld across the NHS," he said.

There are eight million operations performed in Britain each year and around 20,000 patients die after surgery, but it is not known how many might be preventable.

The surgical checklist requires surgeons to run through a series of basic checks (Is this the right patient? Is this the right limb?) in the same way that pilots check their aircraft. It has been described as the biggest clinical innovation in 30 years, after a study by the World Health Organisation in 2008 showed it cut deaths and complications by more than a third.

However, many surgeons dismissed the checklist, saying they were making the checks already and it was too basic. Some adapted the list but experts warned that consistency was vital and each adaptation moved it further away from guaranteeing safety.

At Plymouth's Derriford hospital, which has 35 operating theatres, CQC inspectors found the checklist was "not being fully completed". "We have told the trust that if it does not demonstrate full and consistent compliance with safety checklists from this point forward, our next steps may include prosecution or closure of services," the CQC statement said.

Dr Alex Mayor, the medical director for the Plymouth trust, said none of the six patients had suffered long-term harm. "These events are unacceptable and we are very disappointed. I would like to publicly apologise to anyone affected by these errors.

"Patient safety is paramount and we are determined to ensure there is full and proper compliance with a single, mandatory checklist immediately."

Case study...

Nicola James, 45, was admitted to Derriford Hospital, Plymouth, for a routine gall bladder operation.

Soon after the surgery on 3 November the mother of two began to deteriorate rapidly. She was in severe pain with a distended abdomen and swollen arms and legs.

After three days she was sent for an X-ray, and the next day, a Sunday, she had an ultrasound scan. Surgeons decided to operate immediately and a retained surgical swab was removed.

Neither Mrs James, the daughter of former Lord Mayor of Plymouth David James, nor her family was told about the swab. They were told her bile duct had been "nicked".

Mrs James developed pneumonia and remained in hospital for a further week, seriously ill. Eleven days after the second operation, her parents Diane and David were told about the swab. "The sister called us in. She said the surgeon had been up to see Nicky that morning and had apologised profusely and told her that a swab had been left in her during the first operation. They said they were very sorry," Mr James said.

"My family were distraught. We thought we were going to lose our daughter. We thought she was going to die, but they were so blasé about it.

"Nicola's case happened in November. There was another case in January. They have learned nothing."

A Plymouth Hospitals NHS Trust spokesman, said: "We are extremely sorry for what happened to Ms James and for the distress it has caused. We are undertaking a full investigation."

News
peopleFrankie Boyle responds to referendum result in characteristically offensive style
Arts and Entertainment
Highs and lows of the cast's careers since 2004
News
news
New Articles
i100... with this review
PROMOTED VIDEO
Life and Style
ebooksA superb mix of recipes serving up the freshest of local produce in a delicious range of styles
Life and Style
ebooksFrom the lifespan of a slug to the distance to the Sun: answers to 500 questions from readers
Latest stories from i100
Have you tried new the Independent Digital Edition apps?

ES Rentals

    Independent Dating
    and  

    By clicking 'Search' you
    are agreeing to our
    Terms of Use.

    iJobs Job Widget
    iJobs General

    Cover Supervisor

    £75 - £90 per day + negotiable: Randstad Education Group: Are you a cover supe...

    Marketing Manager - Leicestershire - £35,000

    £30000 - £35000 per annum: Ashdown Group: Marketing Manager (CIM, B2B, MS Offi...

    Marketing Executive (B2B and B2C) - Rugby, Warwickshire

    £22000 - £25000 per annum: Ashdown Group: A highly successful organisation wit...

    SEN Coordinator + Teacher (SENCO)

    £1 per day: Randstad Education Leeds: Job Purpose To work closely with the he...

    Day In a Page

    Scottish referendum: The Yes vote was the love that dared speak its name, but it was not to be

    Despite the result, this is the end of the status quo

    Boyd Tonkin on the fall-out from the Scottish referendum
    Manolo Blahnik: The high priest of heels talks flats, Englishness, and why he loves Mary Beard

    Manolo Blahnik: Flats, Englishness, and Mary Beard

    The shoe designer who has been dubbed 'the patron saint of the stiletto'
    The Beatles biographer reveals exclusive original manuscripts of some of the best pop songs ever written

    Scrambled eggs and LSD

    Behind The Beatles' lyrics - thanks to Hunter Davis's original manuscript copies
    'Normcore' fashion: Blending in is the new standing out in latest catwalk non-trend

    'Normcore': Blending in is the new standing out

    Just when fashion was in grave danger of running out of trends, it only went and invented the non-trend. Rebecca Gonsalves investigates
    Dance’s new leading ladies fight back: How female vocalists are now writing their own hits

    New leading ladies of dance fight back

    How female vocalists are now writing their own hits
    Mystery of the Ground Zero wedding photo

    A shot in the dark

    Mystery of the wedding photo from Ground Zero
    His life, the universe and everything

    His life, the universe and everything

    New biography sheds light on comic genius of Douglas Adams
    Save us from small screen superheroes

    Save us from small screen superheroes

    Shows like Agents of S.H.I.E.L.D are little more than marketing tools
    Reach for the skies

    Reach for the skies

    From pools to football pitches, rooftop living is looking up
    These are the 12 best hotel spas in the UK

    12 best hotel spas in the UK

    Some hotels go all out on facilities; others stand out for the sheer quality of treatments
    These Iranian-controlled Shia militias used to specialise in killing American soldiers. Now they are fighting Isis, backed up by US airstrikes

    Widespread fear of Isis is producing strange bedfellows

    Iranian-controlled Shia militias that used to kill American soldiers are now fighting Isis, helped by US airstrikes
    Topshop goes part Athena poster, part last spring Prada

    Topshop goes part Athena poster, part last spring Prada

    Shoppers don't come to Topshop for the unique
    How to make a Lego masterpiece

    How to make a Lego masterpiece

    Toy breaks out of the nursery and heads for the gallery
    Meet the ‘Endies’ – city dwellers who are too poor to have fun

    Meet the ‘Endies’ – city dwellers who are too poor to have fun

    Urbanites are cursed with an acronym pointing to Employed but No Disposable Income or Savings
    Paisley’s decision to make peace with IRA enemies might remind the Arabs of Sadat

    Ian Paisley’s decision to make peace with his IRA enemies

    His Save Ulster from Sodomy campaign would surely have been supported by many a Sunni imam