FOI requests reveal hospital blunders

Surgeons operating on the wrong side of the body, swabs left inside patients after surgery and the wrong implant being used were among the blunders happening at NHS health services across England last year, freedom of information requests have revealed.

Following FOI requests I made to primary care trusts (PCTs) across England, the figures revealed that at least 6,000 serious untoward incidents (SUIs), which include cases of patients acquiring MRSA in hospital and confidential information leaks, and more than 100 ‘never events’, defined as very serious yet avoidable incidents, occurred during 2011, and these are broken down by PCT.

Never events are serious incidents in healthcare settings which are largely preventable and should therefore never happen, and these fall into 25 categories, such as wrong site surgery, wrong implant/prosthesis, retained foreign object post-operation, and falls from unrestricted windows.

According to my results, the four most common types of never event in 2011 were retained swabs post operation, wrong implant/prosthesis, wrong site surgeries, and misplaced naso- or orogastric tubes, which can cause death if these tubes – used to feed or administer medicines by transferring liquids directly to the stomach – are accidentally placed in the patient’s lung instead.

These never events included:

· A wrong site intervention, where a patient at an ophthalmology clinic had an eye procedure performed on his right eye instead of his left eye (reported by NHS West Essex)

· As an incision was made, surgery theatre staff noticed that the operation had started on the wrong side of the body (reported by NHS North West London)

Tables – data on never events and SUIs at PCTs in England

Below are two tables I have compiled, one on never events and one on SUIs – for more details on the tables and my FOIs, scroll to the bottom of this post.

Bedsores, or pressure ulcers, were the most common type of SUI in 2011, according to the FOI responses I received. Pressure ulcers, most common among the elderly or immobile, are caused by prolonged periods in one position, resulting in the weight of the body pressing down on the skin, and can be prevented by healthcare staff regularly turning and repositioning the patient. 
Peter Walsh, chief executive of the charity Action against Medical Accidents (AvMA), told me that the charity was campaigning for pressure ulcers to be classed as never events in order to ensure that medical staff take greater steps to prevent them happening.

                     “It really is one of the biggest problems in the NHS, and they are perfectly avoidable with appropriate care”

The government drafted an initial list of eight never events in 2009, and this was increased to 25 in 2011 to include severely scalding a patient, wrongly administering insulin and inserting the wrong implant, among other additions. Last year, then health secretary Andrew Lansley said that funding will be held back from hospitals if a never event takes place.

Walsh has previously said he was disappointed that pressure ulcers were not added to the list.

“We have been asking for England to follow the lead of the US by making hospital-acquired pressure ulcers a never event,” Walsh told me. “It really heightens awareness of the need to crack down on the most avoidable things that are continually going wrong in the NHS.

“Pressure ulcers costs thousands of lives and millions upon millions of pounds in extra treatment days. It really is one of the biggest problems in the NHS, and they are perfectly avoidable with appropriate care.

“Acquiring grade 3 or 4 pressure ulcers in hospital is totally unacceptable but it’s happening.”

Walsh said that the arguments against categorising pressure ulcers as never events are that they were “too difficult to define”. In answer to this, he said that the UK should simply follow America’s lead and record and define them like they have done in the States.

               “It’s hard to think of a more avoidable thing than a wrong site surgery or a retained foreign object”

Preventing pressure ulcers goes to the heart of making sure patients receive at least the basic care, said Walsh, such as making sure they have enough food, water and that staff listen to their call bells.

“It’s something about the culture and making sure we have that care and attitude but there’s no escaping that part of the problem relates to understaffing. If nurses simply haven’t got enough time, that’s another contributing factor.”

Walsh pointed out that there are some good examples of improving care in England, such as nurses at Medway Maritime Hospital who helped reduce the number of pressure sores at Medway NHS Foundation Trust by 28% in 2011/2012, and by 39% over the last two years.

As for never events, Walsh said: “By definition, never events really are totally avoidable. You could argue that they are not never events because they do happen, but they should be never events because they are so avoidable just by following established good practice.

Photo: ReSurge International (flickr)

“It’s hard to think of a more avoidable thing than a wrong site surgery or a retained foreign object.”

Most of the never events are covered by NHS patient safety alerts, he said, which highlight safety issues staff should be aware of.

“What we [the AvMA] found was that these alerts, which give guidance on how to avoid things happening, simply weren’t being implemented,” said Walsh.

The World Health Organisation (WHO) has produced a Surgical Safety Checklist for use in operating theatres, so that clinical teams can improve safety by making sure that a checklist is completed for every patient to ensure certain practices and checks are carried out.

“We have heard anecdotally that although trusts have ticked off a response to the list, saying they have implemented it, in practice, some surgeons hate the idea of using a checklist.

“There are certain surgeons who say they are not having any highfalutin checklist to change the way they do things. This results in mistakes being made.”

The FOI figures I have collected are an underestimate, however, as some PCTs, including NHS Surrey and the NHS Merseyside cluster, did not provide me with figures for the dates I requested, January 1 – December 31, 2011, and instead directed me to reports which spanned different periods of time. 

Also, while some PCTs gave me full and detailed figures, others did not give me any at all, and stated that no SUIs or never events happened at the PCT. This appears highly unlikely that absolutely no SUIs happened within the whole of 2011. I wanted to have the figures for all SUIs and never events that happened at every service the PCT was responsible for or had reported to it from its commissioned services. It appears that some PCTs have chosen to interpret my request as meaning that I wasn’t interested in incidents that happened at its commissioned services.
The Department of Health (DH) released figures in October this year showing the number of never events over the past financial year of 2011/2012, which revealed that there were 326 never events reported to Strategic Health Authorities, with the most common types of incident being retained foreign objects post-operation (161 incidents reported), surgery on the wrong part of the body (70 incidents), wrong implant or prosthesis (41 incidents), and misplaced nasogastric tubes (23 incidents). This shows that the PCTs I contacted did not provide me with figures of all the FOIs during 2011.
However, unlike the data provided by the DH, the figures I have collected are broken down by PCT, showing which had the highest number of SUIs and never events – but as some of the PCTs listed in the tables are done by cluster (I have listed PCTs individually where I could, but some clusters did not break down the data by the PCTs within them), this helps explain why some have much higher totals than others, as well as the fact that some PCTs haven’t provided figures for all the SUIs and never events occurring at the services they commission.

Notes about the tables

I have collated the figures in two tables, one covering SUIs and the other covering never events – these show the figures I got in response to my FOIs from the PCTs that replied to my requests. 

I requested data on all SUIs and never events from January 1-December 31, 2011. I also requested investigation reports relating to each never event, which I suggested could be redacted, but very few PCTs gave me these reports, and so I was often provided with very little detail about the never events apart from the category they fell into, rather than what it actually involved e.g. what part of the body was operated on in a wrong site surgery.

In the never events table, because these are fewer in number than SUIs, I have listed brief details of each never event where possible within the Details column. With the SUIs table, however, because there are many more SUIs and different ways that PCTs recorded the incidents, I haven’t included details of every incident by type, but have instead included some figures of note, such as the number of pressure ulcers.

If you would like to use any of the data I have collected via my FOIs, I’d be grateful if you could credit me with finding the figures in any piece you do on it. Also, if anyone would like to have the detailed figures for each PCT, I am happy to provide them with the FOI response in exchange for an attribution or credit within an article, blog post etc. Feel free to get in touch – my details are on my Contact me page on this site.

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© Melanie Hall 2017