A surgeon with over 30 years of experience, operated on the wrong part of a patient’s arm – confessing to his mistake soon after the procedure ended.
Phillip Ivory, 61, had been experiencing numbness in his fingers and underwent elective ulnar nerve decompression surgery to restore feeling at Castle Hill Hospital, in East Yorkshire, in July 2017.
Despite marking Mr Ivory’s arm before he began the procedure, the surgeon made his incision on the outside area of the elbow instead of the inner part where it should have been.
The surgeon realised his mistake shortly after the operation, after thinking about it and realising the operation “did not feel right”. He asked a nurse to unwrap the bandages on Mr Ivory’s arm and explained his mistake.
Mr Ivory has now been awarded damages after bringing a medical negligence claim against Hull and East Yorkshire Hospitals NHS Trust, through specialists Hudgell Solicitors.
Trust admitted fault for an error described as a ‘Never Event’ which should not happen
Hull and East Yorkshire Hospitals NHS Trust, which runs the hospital, admitted breach of duty and completed a serious incident report into the matter.
It deemed the mistake a ‘Never Event’ – errors that the NHS accepts are ‘wholly avoidable’ if the proper checks and procedures are followed.
Mr Ivory, an Area Manager from Bridlington, said the surgeon visited him at his bedside shortly after the operation.
“I said to him ‘everything alright?’ and he never said anything and he asked the nurse to take off the bandage,” he said.
“He then said ‘I’ve done the operation wrong’. I was shocked and I thought he was joking with me so I said ‘we all make mistakes’. Then I thought, ‘Oh no, he’s not joking’.
“He apologised and said he had reported himself to the medical council.”
The patient needed corrective surgery and is still hoping to regain feeling in their fingers
The corrective surgery was delayed as Mr Ivory suffered from unrelated health problems, with angina and then a later diagnosis of diabetes.
The procedure was eventually carried out at Castle Hill Hospital in February 2018, by another surgeon.
Mr Ivory, who is now recovering from the second round of surgery and is waiting to see if he regains the feeling in his fingers, which can take up to a year, said he was shocked that a surgeon “of his calibre” had made such a simple mistake.
“He said it was his first mistake in 32 years, and I do think a surgeon of his calibre should not have got it wrong.
“I couldn’t believe it when he told me, but the inconvenience was the main issue for me, as I was off work for around four weeks each time, so two months in total.
“I know things do happen and things go wrong, and I’m just glad it was something relatively minor, and nothing major. He was very upset. I would say I’ll be glad to see the back of 2017 and 2018, it hasn’t been great.”
‘Never event’ mistakes are ‘unforgivable’ and can prove ‘life-changing’
Mr Ivory said he does not hold any ill feelings towards the surgeon, adding “I think the term ‘Never Event’ is daft, as mistakes can be made.”
However, with ‘Never Events’ being made in their hundreds in hospital wards across the country, including surgical equipment being left inside patients, operations on the wrong limbs, incorrect implants being fitted and the incorrect use of medicines, medical negligence specialist Shauna Pagea, of Hudgell Solicitors, says they are ‘straightforward mistakes’ that are ‘often caused by unnecessary pressures that healthcare practitioners are faced with up and down the country’.
She said: “Mr Ivory has been very understanding of his situation which is a credit to him. He understands people make mistakes. This case has put Mr Ivory back in the position he would have been in were it not for this event”.
“However, we see many cases where mistakes which are completely avoidable have serious, life-changing circumstances”.
“Mr Ivory had to undergo an avoidable second operation, anaesthetic and period of hospitalisation. He now has a second scar. He missed an additional four weeks of work”.
“Fortunately, Mr Ivory has now had the correct surgery and is hopefully on the mend after a difficult year”.