The continuing problem of medical blunders in the NHS across England and Wales is to be highlighted by national current affairs programme ITV Tonight, as figures show completely avoidable errors which cause harm – and even deaths – have reached a four-year high.
‘NHS: Medical Blunders Revealed – Tonight’ will tell the stories of three victims of serious medical mistakes, including one case in which Hudgell Solicitors represented the family of a man who’d had a surgical swab left in him for 13 years after surgery.
The programme will place a focus on ‘wholly preventable’ medical mistakes – known in the medical profession as ‘never events’, as it is fully accepted that they should never happen – which are happening every day in the NHS in England and Wales (465 in 2015/16).
In the case handled by Hudgell Solicitors, Luton and Dunstable Hospital left a swab in patient Frank Hibbard’s pelvis while removing his prostate.
When he died of cancer 13 years later, a coroner said the swab had contributed to his death, as a mass the size of a large grapefruit was found to have grown around the calcified swab when his health deteriorated.
“I watched my dad suffer for years. I watched him go from being very active, he was very fit. I saw him deteriorate to the point that he died an awful death,” Mr Hibbard’s son, Vince, tells the documentary.
“The gauze was about 12 inches in length. It was within his groin and you imagine that in your groin pressing on all your nerves, your bones, your joints.”
Luton and Dunstable University Hospital carried out the operation and also missed the swab in a CT scan two years later. Mr Hibbard died in 2014, just a few months after the gauze was eventually found.
The coroner said it had ‘materially contributed’ to Mr Hibbard developing a type of cancer ‘which ultimately led to his death’.
Families left feeling hospitals ‘don’t care’ when they don’t admit errors – solicitor Renu Daly
Medical negligence solicitor Renu Daly, of Hudgell Solicitors, said it had been a tragic few years for the family, as Mr Hibbard’s wife Christine died this in January, after battling through the legal process to get answers and admissions.
She says families are often angered and upset by a lack of sympathy and accountability when such serious mistakes are made, often leading to them needing legal support to find answers, and secure compensation to help them adapt to life-changing injuries and losses.
One thing that’s quite common when trusts makes mistakes is that a lot of people say ‘Why did they not just say they were sorry? Why didn’t they apologise? Why didn’t they tell me what had happened? Why have I had to go through this process for however long?” said Ms Daly.
If they do get an apology after years of investigation, the apology often has a tendency to sound somewhat hollow, and I can appreciate why they think that. I think the difficulty is when they don’t get an apology at all, despite the evidence being clear that the trust has made an error.
For the families, having to fight for a certain amount of clarity and honesty is something they never thought they’d have to do from the NHS. Sadly, I would say that becoming more common in some areas.
I think for families to receive an apology straight away is so important, I think many trusts or healthcare providers fear that by apologising it’s an admission of guilt or culpability in some avenues.
However, to families and individuals who suffered harm, the lack of apology indicates to them they just didn’t care. They feel ‘they didn’t provide me with enough treatment or appropriate treatment and they don’t care about it and they don’t care about the suffering I’ve been through, or my family’s been through.’
Mix-up saw mum wrongly operated on for breast cancer and another wrongly given all clear
The documentary will also reflect on cases involving a mix-up of test results which led to a woman having her lymph nodes and other parts of her breasts removed after being wrongly told she had grade 2 cancer. The error meant another woman was told she did not have cancer when she did.
Lisa Brewer, 45, from Essex, discovered a lump in her breast just over a year ago and had a number of tests including a mammogram, which she was told was ‘encouraging’. Doctors also took biopsies tissue samples from both breasts, to rule out cancer, but two weeks later she received the news she didn’t want.
Facing the possibility of having both breasts removed, the mum-of-five had life-saving surgery and was left with permanent scarring. But weeks later the hospital revealed it had made a massive blunder.
“It’s weird I didn’t feel relieved, because you can’t just shut emotions off like that straight away,” Lisa tells the ITV documentary.
“Having to tell people that I’d previously told I had cancer, and tell them I didn’t have it, I felt like a fraud in some way.”
Andrew Miles from the Royal College of Surgeons, was interviewed for the documentary and says the pressures in the profession “may be greater just at this moment, than it has been in the past”.
He added: “But there have always been pressures and it’s up to us to cope with it. What we mustn’t do is sacrifice patient’s safety in order to get numbers through.”
In the surgical and medical profession a ‘second victim’ is also referred to, and this is the person who made the mistake. He said he almost operated on the wrong leg during a minor procedure, but the theatre nurse stopped him.
“This was a long time ago, about 25 years ago when I was a registrar and the procedures were different, they did not have the same checks in the system,” said Mr Miles
“We found that the correct leg that I had marked only an hour before, the ink had transferred from one leg to another. That is such a frightening event that even now talking about it just brings me out in a cold sweat.”
NHS looking to learn from ‘no blame’ culture in aviation
The NHS says it takes mistakes very seriously and is now turning to some unexpected quarters for advice, such as the airline industry.
Aviation experts say it has more of a ‘no-blame’ culture when it comes to people being open and honest about reporting mistakes, and it promotes the legal ‘Duty of Candour’ among professionals.
The former Chief Inspector of the Air Accidents Investigations Branch, Keith Conradi, will head up the Healthcare Safety Investigations Branch when it is launched next month.
In response to the ITV programme, Health Secretary Jeremy Hunt said: “We want the NHS to offer the safest and best care anywhere in the world, which means becoming an organisation that consistently learns from its mistakes and makes improvements in the interests of patients, and we have a big programme of reform underway to help achieve that goal.
“From April, all NHS Trusts will be required to publish how many deaths they might have been able to avoid, along with the lessons that they have learned to improve care.”
“The Healthcare Safety Investigation Branch will help the NHS learn from mistakes in the same way that the airline industry does and improve the quality of investigations across the NHS.