Patient had breast biopsy 'on wrong side' in hospital blunder
PUBLISHED: 05:30 14 September 2019 | UPDATED: 16:32 18 September 2019
A patient had a breast biopsy on the wrong side which was reported as a serious 'never event' at West Suffolk Hospital, it can be revealed.
Named that way because they are never supposed to happen, seven 'never events' were reported at the East Suffolk and North Essex Foundation Trust (ESNEFT), which runs Ipswich and Colchester hospitals, in 2018-19.
A further two have been reported in the trust's board papers for 2019-20.
At West Suffolk Hospital, one of two 'never events' in 2018-19 saw a patient have a punch breast biopsy on the wrong side - before having to endure the procedure all over again on the correct side. Trust bosses say the patient did not suffer any harm.
Other 'never events' included:
- A swab left inside a patient after surgery at Ipswich Hospital's maternity department
- The wrong side of a patient's back was injected with local anaesthetic ahead of spinal surgery, also at Ipswich
- The wrong prosthetic was inserted into a patient's knee at Colchester Hospital
- Medication was administered via the wrong route, also at Colchester
There were also more than 200 serious incidents recorded across Ipswich, Colchester and West Suffolk hospitals in 2018-19 - with 186 at ESNEFT, and 42 at West Suffolk.
Treatment delays, surgical problems, pressure ulcers and maternity incidents among the most common complaints.
Andy Yacoub, chief executive of Healthwatch Suffolk, branded some of the incidents "truly shocking".
He said the hospitals must learn from never events and act, so the public is reassured they won't be repeated.
"Though they are rare, never events are nonetheless very serious medical errors with potential consequences for patients and their families," he added.
"Some of these events are truly shocking and, without proper scrutiny and transparent learning, can undermine the confidence people have in our local services."
The watchdog's chief executive added: "The hospitals must learn from never events and act - informing all those who need to make changes in, for example, decision making so the public can be assured such occurrences will not be repeated.
"Patients and carers tell us they generally rate our local hospitals highly. Trust and respect is built on good experiences of services and of being listened to.
"It is therefore our position that it would be worthwhile for the hospitals to publicly talk about, and demonstrate, how they have worked with patients, carers and families affected by these shocking events to learn from what happened and ensure they never reoccur."
Trust 'sorry' for incidents
Rowan Procter, executive chief nurse at the West Suffolk Hospital, said the trust saw more than 74,000 patients in their A&E and cared for more than 36,000 patients on their wards in 2018-19.
"We take reported incidents seriously," she added.
"Neither patient involved in our two reported never events suffered harm and both have received a full, unreserved, apology.
"In these cases, guidance wasn't followed correctly and we've since made changes to our procedures to make them more robust and reduce the risk of something similar happening again."
'One too many'
And ESNEFT spokeswoman Jan Ingle said any never event is one too many.
"The number of never events does need to be put into context of how large the trust is now, and the fact that we care for over 10,000 people a day," she added.
"However, any never event is one too many.
"Every serious incident is investigated thoroughly and findings are shared with the patients and their families.
"An enormous amount of work is done to make sure we learn from them."