Lancashire TelegraphHospital bosses sorry after swab left inside second East Lancs patient (From Lancashire Telegraph)

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Hospital bosses sorry after swab left inside second East Lancs patient

Lancashire Telegraph: Royal Blackburn Hospital Royal Blackburn Hospital

HOSPITAL bosses have again pledged to ‘learn lessons’ after it emerged a second patient had a swab left inside their body after surgery.

The latest blunder happened at the Royal Blackburn Hospital and resulted in the patient undergoing a further operation to retrieve the swab.

The incident was listed in newly-published NHS papers and has been classed as a ‘never event’, which is an incident deemed so serious that it should never happen in the NHS.

East Lancashire Hospitals NHS Trust (ELHT) said the swab was removed in the same theatre session and the patient was not harmed, but said it could not release further details due to strict rules around patient confidentiality. The incident happened in March.

The Royal College of Surgeons said the error was ‘extremely serious and completely unacceptable’, due to the risk of infections and the need for further surgery.

It comes after a swab was left inside a woman in the maternity department at Burnley General Hospital, also run by ELHT, in July last year.

Russ McLean, chairman of the Pennine Lancashire Patient Voices Group, said: “I’m appalled to hear of this latest incident and quite frankly I am worried too.

“There was a similar incident last year and the trust assured us that lessons would be learned and processes would be put in place to ensure that this kind of thing would not happen again.

“For goodness sake ELHT, for the sake of your patients and the future of our hospitals, please get your act together.”

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.

News of the incident comes as the Care Quality Commission (CQC) prepares to publish a crucial inspection report on ELHT this week, which bosses hope will persuade the NHS to lift the trust out of ‘special measures’.

Last year’s incident in Burnley was initially classed as a never event, but has since been downgraded to a ‘serious’ incident, as it did not require another procedure.

The patient, a 25-year-old mum from Blackburn, spoke to the Lancashire Telegraph earlier this year, claiming the swab had been left inside her for about two weeks and left her ‘screaming in pain’.

She returned to the hospital after her mother advised her the level of pain and swelling was abnormal, and the swab was removed without surgery.

An investigation resulted in a new system where all surgical patients in obstetrics and gynaecology now have a purple wristband placed on them for each swab, or surgical pack inserted.

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

The wristband system was thought to be impractical for other divisions, however, as many more swabs are generally inserted than in obstetrics and gynaecology, where only a few might be used.

Never events frequently result in a compensation bid from the patient or their family, but ELHT refused to say whether a claim had been made.

Dr Ian Stanley, acting medical director at ELHT, said: “The situation in March is very different from the incident (last) summer, but the lesson we have learned is around ensuring that there is an individual responsible for confirming that a swab count is correct.

“On this occasion there was miscommunication between staff, and the patient was woken up when the swab count had not been confirmed as correct.”

“Quality and safety remain our main priority and it’s always a concern when we don’t meet these high standards. On both occasions we have been open and honest with the patient and a full apology given.”

He said the decision to downgrade the seriousness of the incident last summer had been confirmed by commissioners and NHS England.

The trust performs more than 33,000 operations each year, he added.

A spokesman for The Royal College of Surgeons said: “Leaving swabs, or any foreign object behind after surgery, is extremely serious because of the risk of infections and the need for further surgery.

“Never events are incidents that are completely unacceptable. However rare they are, never should mean never.

“Educating the entire surgical team is fundamental to learning about and preventing never events. The pre and post operative check lists should involve all theatre staff and are designed to prevent events.”

Blackburn MP Jack Straw said: “Any incident like this is serious but extremely rare. There’s a new chief executive coming into the trust and I feel more confident about the future.”

There were 312 never events across the whole of the NHS in 2013/14, according to NHS figures.

Comments (17)

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10:08am Mon 7 Jul 14

vicn1956 says...

I remember watching a 50's film of an operation where a nurse counted all swabs used and put them up on a rack as proof.
Who decided that that was too "old-fashioned" ?

Don't need to learn lessons. It's common sense. But too often sense isn't common any more!
I remember watching a 50's film of an operation where a nurse counted all swabs used and put them up on a rack as proof. Who decided that that was too "old-fashioned" ? Don't need to learn lessons. It's common sense. But too often sense isn't common any more! vicn1956
  • Score: 43

10:27am Mon 7 Jul 14

Izanears says...

Am I the only person who is fed up of hearing 'officials' using the words "lessons will be learned, or "lessons have been learned" to cover up mistakes or flaws in the system? If they do not know what they are doing by now they never will.
Am I the only person who is fed up of hearing 'officials' using the words "lessons will be learned, or "lessons have been learned" to cover up mistakes or flaws in the system? If they do not know what they are doing by now they never will. Izanears
  • Score: 41

10:33am Mon 7 Jul 14

vicn1956 says...

Another 50-60 meetings to decide-nothing.
Another 50-60 meetings to decide-nothing. vicn1956
  • Score: 26

11:45am Mon 7 Jul 14

Summer18 says...

I just dont know how in 2014 this can happen........http:/
/royalestones.co.uk/
index.php?route=comm
on/home
I just dont know how in 2014 this can happen........http:/ /royalestones.co.uk/ index.php?route=comm on/home Summer18
  • Score: 16

3:18pm Mon 7 Jul 14

woolywords says...

Izanears wrote:
Am I the only person who is fed up of hearing 'officials' using the words "lessons will be learned, or "lessons have been learned" to cover up mistakes or flaws in the system? If they do not know what they are doing by now they never will.
Can I type, St Elsewhere, again, or are you bored with that too?
[quote][p][bold]Izanears[/bold] wrote: Am I the only person who is fed up of hearing 'officials' using the words "lessons will be learned, or "lessons have been learned" to cover up mistakes or flaws in the system? If they do not know what they are doing by now they never will.[/p][/quote]Can I type, St Elsewhere, again, or are you bored with that too? woolywords
  • Score: 7

4:28pm Mon 7 Jul 14

krissy1985 says...

2nd time what a load of rubbish i no someone who went through this when maternity ward was at blackburn ....didnt even get an apology just it was a mistake .....nhs once again hiding the truth ... dont have much confidence in them anymore dont thinkm i ever will
2nd time what a load of rubbish i no someone who went through this when maternity ward was at blackburn ....didnt even get an apology just it was a mistake .....nhs once again hiding the truth ... dont have much confidence in them anymore dont thinkm i ever will krissy1985
  • Score: 13

5:32pm Mon 7 Jul 14

noddy57 says...

It seems to me like this hospital makes a habit of forgetting things.
It seems to me like this hospital makes a habit of forgetting things. noddy57
  • Score: 7

6:24pm Mon 7 Jul 14

mavrick says...

I have tried to defend the NHS for years but lessons are never learnt. I have seen the RBH replace the old BRI and Queens park in a move we were all assured of top clinicians and cutting edge medicine. Then the Accountants got in charge and it went downhill from there. The coalition say it cost's too much. Remember the NHS and the welfare state were created after a world war which left us with less money to start these massive social systems, It is our NHS and we need to fight for it and let the politicians know the consequences of attacking the NHS.
I have tried to defend the NHS for years but lessons are never learnt. I have seen the RBH replace the old BRI and Queens park in a move we were all assured of top clinicians and cutting edge medicine. Then the Accountants got in charge and it went downhill from there. The coalition say it cost's too much. Remember the NHS and the welfare state were created after a world war which left us with less money to start these massive social systems, It is our NHS and we need to fight for it and let the politicians know the consequences of attacking the NHS. mavrick
  • Score: 8

6:54pm Mon 7 Jul 14

pwitch says...

When I was a student nurse in the 50's there was a stand where all the used swabs were put on display in the theatre by a nurse to be counted by the surgeon before the wound was stitched up. The counting was duplicated by the surgery assistant to make sure everything was in order. The swabs were in batches of ten I think to make for easy counting after each new batch was opened and the used display was also in batches of ten.
When I was a student nurse in the 50's there was a stand where all the used swabs were put on display in the theatre by a nurse to be counted by the surgeon before the wound was stitched up. The counting was duplicated by the surgery assistant to make sure everything was in order. The swabs were in batches of ten I think to make for easy counting after each new batch was opened and the used display was also in batches of ten. pwitch
  • Score: 9

7:03pm Mon 7 Jul 14

adamdesk says...

it seems a deliberate act because the surgeon doesn't like the job

How on earth can you leave such thing inside a human
it seems a deliberate act because the surgeon doesn't like the job How on earth can you leave such thing inside a human adamdesk
  • Score: -4

7:14pm Mon 7 Jul 14

phil kernot says...

Lessons have been learned ,, , less managers and more surgeons and it shouldn't happen ,, surgeons are under constant pressure to do as many ops as possible ,, to pay for the useless managers that we don't need ,,,
Lessons have been learned ,, , less managers and more surgeons and it shouldn't happen ,, surgeons are under constant pressure to do as many ops as possible ,, to pay for the useless managers that we don't need ,,, phil kernot
  • Score: 9

7:52pm Mon 7 Jul 14

shazadi says...

yet again more blunders! Christine Pearson. Ian Stanley medical director and the chief executive I call for your resignation. how many more preventable deaths and blunders will it take before you go. I hope the report published this week by the CQC puts is place special measures to sack you all. you disgrace me.
yet again more blunders! Christine Pearson. Ian Stanley medical director and the chief executive I call for your resignation. how many more preventable deaths and blunders will it take before you go. I hope the report published this week by the CQC puts is place special measures to sack you all. you disgrace me. shazadi
  • Score: -3

8:14pm Mon 7 Jul 14

SHthirty says...

This is diabolicle. I was a scrub nurse before i retired and it seems to me the scrub nurse involved in this case hasn't performed his/her basic checks before the patients wound has been closed. In my day it was the scrub nurses responsibility to make sure all swabs were accounted for and the surgeon informed that the count was correct before the wound was closed never mind allowing the patient to be woken up. This was a standard/basic policy...obviously things have changed.
This is diabolicle. I was a scrub nurse before i retired and it seems to me the scrub nurse involved in this case hasn't performed his/her basic checks before the patients wound has been closed. In my day it was the scrub nurses responsibility to make sure all swabs were accounted for and the surgeon informed that the count was correct before the wound was closed never mind allowing the patient to be woken up. This was a standard/basic policy...obviously things have changed. SHthirty
  • Score: 10

10:19am Tue 8 Jul 14

vicn1956 says...

Is the obsession with managers to oversee targets and paying for PFI leading to disaster?
Who brought those two things in?
£30billion hole in NHS. Something will have to give!
Is the obsession with managers to oversee targets and paying for PFI leading to disaster? Who brought those two things in? £30billion hole in NHS. Something will have to give! vicn1956
  • Score: 3

6:06pm Tue 8 Jul 14

zabby says...

New labour flagship hospital
New labour flagship hospital zabby
  • Score: 1

6:49pm Tue 8 Jul 14

kapalski says...

Disgraceful, no other words. Yes we are all human an we make mistakes but this is not acceptable, what disciplinary procedures are in place here, and who is actually accountable for this??

We, the people of Lancashire need our own cure the nhs/ ELHT, we need our own Julie Bailey!!
Disgraceful, no other words. Yes we are all human an we make mistakes but this is not acceptable, what disciplinary procedures are in place here, and who is actually accountable for this?? We, the people of Lancashire need our own cure the nhs/ ELHT, we need our own Julie Bailey!! kapalski
  • Score: 2

8:19pm Thu 10 Jul 14

issabella says...

this should never never happen that is why it is called a never event . there are checks in place before the operation , during the operation,before the close of the abdomen and at the end of the procedure. there is also the WHO safer surgery which specifically asked if swabs are correct at the end. the scrub nurse is responsible for checking with a circulating nurse then informing the surgeon if the count is not correct then procedures should be followed . as a retired theatre sister I am horrified that this has happened as there are policies and procedures in place to prevent this . lessons dont need to be learnt it shouldnt happen as all staff should be competent .
this should never never happen that is why it is called a never event . there are checks in place before the operation , during the operation,before the close of the abdomen and at the end of the procedure. there is also the WHO safer surgery which specifically asked if swabs are correct at the end. the scrub nurse is responsible for checking with a circulating nurse then informing the surgeon if the count is not correct then procedures should be followed . as a retired theatre sister I am horrified that this has happened as there are policies and procedures in place to prevent this . lessons dont need to be learnt it shouldnt happen as all staff should be competent . issabella
  • Score: 3
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