Swab left inside patient at Burnley General Hospital

Burnley and Pendle Citizen: Change in procedures at Burnley General after swab error Change in procedures at Burnley General after swab error

A SWAB was left inside a woman’s body after surgery, it has been revealed.

As a result of the incident at Burnley General Hospital's Women and Newborn Centre for East Lancashire, hospital bosses have changed their procedures.

Staff now use purple wristbands to remind them to remove surgical items from patients’ bodies following what hospital chiefs have classed as a ‘never event’ - something so serious it should never happen in the NHS.

Nationally, there have been cases of swabs being left inside patients for several days, even weeks, though East Lancashire Hospitals NHS Trust refused to say how long it was until the blunder was noticed or how the swab was removed.

Bosses did say the incident had ‘no further harm or detrimental effect on the patient’.

Russ McLean, chairman of the Pennine Lancashire Patient Voices Group, said: "I was absolutely appalled to learn of this incident and my thoughts are with the patient, having had to endure this violation.

“I am aware that the trust works hard to ensure that never events are just that: events which never happen - but there is quite obviously room for improvement. Let's hope that lessons have been learned.”

Bosses said the incident happened within the obstetrics and gynaecology division at Burnley General Hospital on July 28, but claimed patient confidentiality would be breached by releasing any further details, despite the Lancashire Telegraph requesting an anonymous account.

Surgical swabs, which are wads of absorbent material, are routinely used to contain bleeding in surgery, and careful steps should always be taken to make sure they are removed.

An investigation into the incident has resulted in a new system where all surgical patients now have a purple wristband placed on them for each swab, or surgical pack, which is inserted.

The bands act as a ‘visual reminder’ to clinicians that items still need to be removed once bleeding has stopped.

The case falls into the ‘never event’ category labelled ‘retained instrument post-operation’, which is defined as: “One or more instruments or swabs, or a throat pack, are unintentionally retained following an operative procedure, and an operation or other invasive procedure is needed to remove this, and/or there are complications to the patient arising from its continued presence.

Stephen Jones, a specialist in medical negligence cases at Manchester law firm Pannone, said: “It amazes us in this day and age that this sort of incident continues to happen when proper procedures should make it something of the past.

“These events should never happen. It’s important that hospitals learn from them to prevent them from happening again.

“It also important that patients are informed about what steps have been taken.”

Gordon Birtwistle, MP for Burnley, said: “A foreign body being left inside a patient is really frightening. Someone down the line clearly hasn’t done their job and they need to make sure it doesn’t happen again.”

Never events frequently result in a compensation bid from the patient or their family, but ELHT said it had not been notified of any legal claim.

There has not been any disciplinary action against any staff in connection with the incident, the trust added.

Recent national figures showed about 750 never events occurred across the NHS from 2009 - 2012, with just one of these reported in East Lancashire.

Simon Hill, clinical director for family care at the trust, said the patient received an apology and explanation as to how the incident occurred.

He added: “I can appreciate how concerning this may be for patients and relatives, however I can assure you that it is extremely rare for such events to occur. An independent review has been carried out and the recommendations are being implemented.”

Comments (5)

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10:38am Thu 12 Dec 13

Mikeee47 says...

Purple wrist bands? how much do they cost the NHS? Might as well tie a knot in a handkerchief.
What happened to the old system Count how many swab are on the table before surgery, and how many are there after the procedure, 1 missing where is it? Nothing else was done 'till it was found.
Yet more Incompetence from Uncaring staff
Purple wrist bands? how much do they cost the NHS? Might as well tie a knot in a handkerchief. What happened to the old system Count how many swab are on the table before surgery, and how many are there after the procedure, 1 missing where is it? Nothing else was done 'till it was found. Yet more Incompetence from Uncaring staff Mikeee47

11:01am Thu 12 Dec 13

Izanears says...

I really must go to Specsavers. I thought the headline read SWAN left inside patient!
I really must go to Specsavers. I thought the headline read SWAN left inside patient! Izanears

11:03am Thu 12 Dec 13

Izanears says...

Seriously though. I always thought that instruments, swabs and other equipment was counted both before and after an operation. Obviously not.
Seriously though. I always thought that instruments, swabs and other equipment was counted both before and after an operation. Obviously not. Izanears

6:33pm Thu 12 Dec 13

Robs83 says...

I would just like to point out the figures disclosed in this article, 750 'never events' in a three year period, ONE of which was reported in East Lancs. I absolutely understand that one never event is one too many, however to call staff incompetent and uncaring is ridiculous!! Why else to people go into a nursing career? Is it the lucrative pay packet? The incredibly social hours?? Or the sheer joy of working on Christmas Day?? I think somebody has totally missed the point of the article!! I'm certain that staff will have learnt lessons from this incident and will strive to ensure this never happens again.
I would just like to point out the figures disclosed in this article, 750 'never events' in a three year period, ONE of which was reported in East Lancs. I absolutely understand that one never event is one too many, however to call staff incompetent and uncaring is ridiculous!! Why else to people go into a nursing career? Is it the lucrative pay packet? The incredibly social hours?? Or the sheer joy of working on Christmas Day?? I think somebody has totally missed the point of the article!! I'm certain that staff will have learnt lessons from this incident and will strive to ensure this never happens again. Robs83

9:58pm Thu 12 Dec 13

Sajdin says...

Robs83 wrote:
I would just like to point out the figures disclosed in this article, 750 'never events' in a three year period, ONE of which was reported in East Lancs. I absolutely understand that one never event is one too many, however to call staff incompetent and uncaring is ridiculous!! Why else to people go into a nursing career? Is it the lucrative pay packet? The incredibly social hours?? Or the sheer joy of working on Christmas Day?? I think somebody has totally missed the point of the article!! I'm certain that staff will have learnt lessons from this incident and will strive to ensure this never happens again.
I have said the same, if you look at other Trusts, who in actual fact are smaller in size and serve a smaller population, the amount of never events is shocking. One never event in the Trust and LET have hatched on!
[quote][p][bold]Robs83[/bold] wrote: I would just like to point out the figures disclosed in this article, 750 'never events' in a three year period, ONE of which was reported in East Lancs. I absolutely understand that one never event is one too many, however to call staff incompetent and uncaring is ridiculous!! Why else to people go into a nursing career? Is it the lucrative pay packet? The incredibly social hours?? Or the sheer joy of working on Christmas Day?? I think somebody has totally missed the point of the article!! I'm certain that staff will have learnt lessons from this incident and will strive to ensure this never happens again.[/p][/quote]I have said the same, if you look at other Trusts, who in actual fact are smaller in size and serve a smaller population, the amount of never events is shocking. One never event in the Trust and LET have hatched on! Sajdin

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