A piece of equipment was left inside a patient who underwent surgery at one of the main acute hospitals serving patients from Powys, a report has revealed.
The mistake happened when part of a tool broke off during a procedure, but went unnoticed as theatre staff failed to follow the hospital’s theatre count policy.
A report to the board of Shrewsbury and Telford Hospital NHS Trust (SaTH) says the incident was classed as a ‘never event’ – the name given to incidents that are considered so serious they should never happen.
It was one of 12 incident investigations to be completed in May and June.
The report says the patient was undergoing a transurethral resection of the prostate (TURP), an operation to cut away a section of the prostate, when the device used to carry out the procedure, called a resectoscope, broke.
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It says: “When the piece of equipment was thought to be lost, the correct procedure, as per the trust’s theatre count policy, was not adhered to.
“Resectoscope loops have always been manipulated by urology surgeons for some patients where a better cut is required.
“It is not uncommon for the loop to lose its integrity and break, but the side electrode is not expected to break."
The report says the error caused the patient “increased pain and anxiety”, and he also had to have a catheter for longer than would otherwise have been necessary.
A number of actions have been taken following the investigation, including extra training and ensuring all theatre staff are aware of the correct process to follow regarding lost equipment.
The trust’s induction programme for agency staff will also be reviewed.
Among the 11 serious incident investigations concluded during the reporting period was a delayed lung cancer diagnosis, which “likely caused [the patient’s] disease to progress which limited his treatment options and impacted his prognosis”.
The report says it was due to an error in the x-ray archiving and communication system, compounded by “an unprecedented backlog in reporting due to workforce capacity and demand on the service”.
In another incident, delayed diagnosis and treatment due to overcrowding in A&E “led to a deterioration in the patient condition resulting in cardiac arrest”.
The investigation found that, while there was some learning to take from the incident, the patient’s death could not have been prevented.
The remainder of the investigations involved falls, pressure ulcers, other cases of delayed diagnosis and treatment, and an inappropriate discharge.
During May and June there were no ‘never events’ recorded, the report says.
However there were 16 serious incidents which are now subject to investigations.
They included seven cases of delayed diagnosis, and a baby receiving birth trauma injuries in a “difficult” caesarean.
The report will be discussed at a meeting of the trust’s board on Thursday.
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