Guy’s and St Thomas’ surgeons accidentally operate on wrong patients or body parts ten times in two years

Josh Salisbury (20 February, 2020) Health

Surgeons also left objects inside patients' bodies after operations twice in just one month last year

18011Guy's Hospital (pictured)

Surgeons at Guy’s and St Thomas’ Trust have operated on the wrong body parts or the wrong patient ten times in the past two years, the News can reveal.

Freedom of Information data reveals the number and types of completely preventable patient safety incidents at the Trust which had “potential to cause serious harm or death” in 2018 and 2019.

The most common type of these so-called ‘Never Events’ was wrong site surgery, occurring ten times in two years, meaning an invasive procedure was carried out on either the wrong person or wrong body part.

The data also reveals how a Never Event in December last year saw staff give a patient the wrong implant from the one that had been planned.

And in two separate incidents in just one month last year, surgeons left behind objects inside the patient’s body after an operation.

Further details of these “retained foreign objects” was not given, but they can include needles, surgical instruments and swabs.

The Trust says it is takes such incidents extremely seriously and that the number of incidents are reflective of growing patient numbers.

Never Events are the highest ranking of patient safety ‘serious incidents’ which all hospitals are required to declare for investigation.

Guy’s and St Thomas’ declared 185 serious incidents in those two years, of which seventeen were Never Events.

The Trust did not provide details of which cases took place in which hospitals, despite being asked under FOI law to do so.

Other Never Event lapses of patient safety declared in the hospitals was an occasion in which a patient was given an accidental overdose of insulin, and another in which a patient who needed oxygen was instead given medical air.

A Trust spokesperson said the hospitals were committed to providing “high quality care” and that it took such incidents “extremely seriously.”

Exterior of St Thomas’ Hospital

“As a Trust, we encourage reporting as part of an open and transparent culture and all serious incidents and never events reported in 2018 and 2019 were fully investigated so we can ensure lessons learnt were shared across the Trust,” she said.

“Guy’s and St Thomas’ is one of the largest Trusts in the country and in the year 2018/19 we had around 2.6 million patient contacts.

“We are treating and seeing more patients than ever before and this is reflected in the number of incidents that are reported.”

The Care Quality Commission, which inspects hospitals, rated Guy’s and St Thomas’ as ‘Good’ in its latest inspection last year.

Although the Trust was served with a ‘requires improvement’ under the category of ‘Are services safe?’ inspectors noted “a well-established system to report, investigate and learn from incidents.”

The Trust runs two main hospital sites, Guy’s Hospital in London Bridge and St Thomas’ Hospital, alongside the Evelina London Children’s Hospital.

The News is requesting the same data from all hospitals serving Southwark.

The Full list of ‘never events’ recorded in the past two years at Guy’s & St Thomas’:

Never Events in 2018:

  • February: Wrong Site Surgery
  • April: Wrong Site Surgery
  • July: Wrong Site Surgery
  • August: Wrong Site Surgery
  • October: Unintentional connection of a patient requiring oxygen to an air flowmeter
  • October: Overdose of insulin due to abbreviations or incorrect device
  • November: Wrong Site Surgery
  • November: Wrong Site Surgery
  • November: Wrong Site Surgery

Never Events in 2019:

  • March: Wrong Site Surgery
  • May: Retained Foreign Object
  • May: Misplaced naso or oro-gastric tubes
  • May: Retained Foreign Object
  • June: Wrong Site Surgery
  • July: Wrong route administration of medication
  • September: Wrong Site Surgery
  • December: Wrong implant


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