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."

Life and Style
Small winemakers say the restriction makes it hard to sell overseas
food + drink
Arts and Entertainment
A comedy show alumni who has gone on to be a big star, Jon Stewart
tvRival television sketch shows vie for influential alumni
Arts and Entertainment
Carrie Hope Fletcher
booksFirst video bloggers conquered YouTube. Now they want us to buy their books
News
Clare Balding
peopleClare Balding on how women's football is shaking up sport
PROMOTED VIDEO
Life and Style
ebookNow available in paperback
Life and Style
ebooksA superb mix of recipes serving up the freshest of local produce in a delicious range of styles
Arts and Entertainment
Damien Hirst
artCoalition's anti-culture policy and cuts in local authority spending to blame, says academic
Sport
premier leagueMatch report: Arsenal 1 Man United 2
Arts and Entertainment
Kirk Cameron is begging his Facebook fans to give him positive reviews
film
News
i100
Sport
Jonny May scores for England
rugby unionEngland 28 Samoa 9: Wing scores twice to help England record their first win in six
Life and Style
fashionThe Christmas jumper is in fashion, but should you wear your religion on your sleeve?
Arts and Entertainment
Jason goes on a special mission for the queen
tvReview: Everyone loves a CGI Cyclops and the BBC's Saturday night charmer is getting epic
Arts and Entertainment
Jerry Hall (Hand out press photograph provided by jackstanley@theambassadors.com)
theatre
Sport
Tony Bellew (left) and Nathan Cleverly clash at the Echo Arena in Liverpool
boxingLate surge sees Liverpudlian move into world title contention
Voices
Neil Findlay
voicesThe vilification of the potential Scottish Labour leader Neil Findlay shows how one-note politics is today, says DJ Taylor
Life and Style
food + drinkMeat-free recipes and food scandals help one growing sector
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

    Reach Volunteering: Financial Trustee and Company Secretary

    Voluntary Only - Expenses Reimbursed: Reach Volunteering: A trustee (company d...

    Recruitment Genius: Senior Project Manager

    £45000 - £65000 per annum: Recruitment Genius: This is a fantastic opportunity...

    Recruitment Genius: Shopfitter

    Negotiable: Recruitment Genius: This is an opportunity to join a successful an...

    Recruitment Genius: Digital Sales Account Manager

    £25000 - £30000 per annum: Recruitment Genius: A Digital Sales Account Manager...

    Day In a Page

    Mau Mau uprising: Kenyans still waiting for justice join class action over Britain's role in the emergency

    Kenyans still waiting for justice over Mau Mau uprising

    Thousands join class action over Britain's role in the emergency
    Isis in Iraq: The trauma of the last six months has overwhelmed the remaining Christians in the country

    The last Christians in Iraq

    After 2,000 years, a community will try anything – including pretending to convert to Islam – to avoid losing everything, says Patrick Cockburn
    Black Friday: Helpful discounts for Christmas shoppers, or cynical marketing by desperate retailers?

    Helpful discounts for Christmas shoppers, or cynical marketing by desperate retailers?

    Britain braced for Black Friday
    Bill Cosby's persona goes from America's dad to date-rape drugs

    From America's dad to date-rape drugs

    Stories of Bill Cosby's alleged sexual assaults may have circulated widely in Hollywood, but they came as a shock to fans, says Rupert Cornwell
    Clare Balding: 'Women's sport is kicking off at last'

    Clare Balding: 'Women's sport is kicking off at last'

    As fans flock to see England women's Wembley debut against Germany, the TV presenter on an exciting 'sea change'
    Oh come, all ye multi-faithful: The Christmas jumper is in fashion, but should you wear your religion on your sleeve?

    Oh come, all ye multi-faithful

    The Christmas jumper is in fashion, but should you wear your religion on your sleeve?
    Dr Charles Heatley: The GP off to do battle in the war against Ebola

    The GP off to do battle in the war against Ebola

    Dr Charles Heatley on joining the NHS volunteers' team bound for Sierra Leone
    Flogging vlogging: First video bloggers conquered YouTube. Now they want us to buy their books

    Flogging vlogging

    First video bloggers conquered YouTube. Now they want us to buy their books
    Saturday Night Live vs The Daily Show: US channels wage comedy star wars

    Saturday Night Live vs The Daily Show

    US channels wage comedy star wars
    When is a wine made in Piedmont not a Piemonte wine? When EU rules make Italian vineyards invisible

    When is a wine made in Piedmont not a Piemonte wine?

    When EU rules make Italian vineyards invisible
    Look what's mushrooming now! Meat-free recipes and food scandals help one growing sector

    Look what's mushrooming now!

    Meat-free recipes and food scandals help one growing sector
    Neil Findlay is more a pink shrimp than a red firebrand

    More a pink shrimp than a red firebrand

    The vilification of the potential Scottish Labour leader Neil Findlay shows how one-note politics is today, says DJ Taylor
    Bill Granger recipes: Tenderstem broccoli omelette; Fried eggs with Mexican-style tomato and chilli sauce; Pan-fried cavolo nero with soft-boiled egg

    Oeuf quake

    Bill Granger's cracking egg recipes
    Terry Venables: Wayne Rooney is roaring again and the world knows that England are back

    Terry Venables column

    Wayne Rooney is roaring again and the world knows that England are back
    Michael Calvin: Abject leadership is allowing football’s age-old sores to fester

    Abject leadership is allowing football’s age-old sores to fester

    Those at the top are allowing the same issues to go unchallenged, says Michael Calvin