New NHS figures have highlighted a ‘worrying trend’ across England’s health trusts as dozens of patients are being sent home after treatment with surgical swabs left inside them.
Figures revealing the ‘serious, largely preventable mistakes’ made on patients across England show that 53 people were sent home with ‘retained swabs’ still in their bodies between April 1 2021 and March 2022.
This is an increase on previous years, and comes as details have been revealed of other ‘retained objects’ left in patients over the 12 month period, including part of a drill bit, part of a pair of wire cutters and a scalpel blade.
Produced by NHS England and NHS Improvement, the figures form part of the annual ‘Never Events’ report – a list that details the mistakes made which should always be avoided by healthcare providers by following national guidance or safety recommendations.
Other errors listed include operations being carried out on the wrong patients, operations including eye injections being carried out when they were not required, patients being given the wrong blood by transfusion and patients who needed oxygen being unintentionally connected to air flow meters.
Increase in vaginal swabs being retained in patients
Helena Wood, a specialist in investigating incidents of medical negligence at Hudgell Solicitors, highlighted the increase in the number of swabs being retained in patients when assessing the NHS report, saying cases relating to vaginal swabs are a particular concern.
The report reveals 21 surgical swabs and 32 vaginal swabs were left in patients in error between April 1 2021 and March 2022. The previous year 15 surgical swabs and 23 vaginal swabs were left in patients – a total of 38.
Ms Wood also says it is a concern that overall cases of Never Events are not falling significantly, with 407 recorded over the period of April 1 to March 31 2021-22
“Given the concept of Never Events is not about apportioning blame to organisations when these incidents occur, but to learn from what happened, it is a concern that year after year the number of incidents is always a similar figure and, in only one of the past seven years has it fallen below 400,” said Ms Wood.
“There appears to be a worrying trend in terms of vaginal swabs being retained in patients. As a firm, we have represented a number of women who have given birth or undergone gynaecological surgery and have experienced unexplained and significant pain in the days and weeks afterwards, which can be a sign of infection developing.
“We have supported women who have struggled for months in pain after giving birth, during which time bonding with their newborn baby has been impacted, as they have been left feeling so ill.
“We were recently instructed on a case, and secured compensation, for a lady who took active steps to avoid becoming pregnant again as she was so badly affected by the pain and suffering she endured.
“Swabs are routinely used by obstetricians and midwives during caesarean sections or during surgery after birth, and a retained surgical swab often leads to significant pain, in many cases infection, and often psychological injuries too.
“It is usual practice for two healthcare professionals to count surgical swabs at the beginning of a procedure, halfway through and at the end. There should not be any confusion.
“These really are cases which we should not be seeing year after year on these reports and it is a worrying trend to see it increasing, particularly with regards to the use of vaginal swabs, given the number has gone from 18 two years ago to 32 in these latest annual figures.”
Manchester, Nottingham and Birmingham Trusts see sharp rises in cases
The total number of Never Events recorded on the provisional published list for the period between April 1st 2021 and March 31 2022 is 407, up from 364 the previous year and a fall from the 2019 to 2020 figure of 472.
The report also lists the number of Never Events recorded by individual health trusts, with some seeing a sharp rise in incidents to previous years.
One of the most significant rises has come at Nottingham University NHS Trust, which recorded 10 Never Events between April 2021 and March 2022. These included five cases of wrong-site surgery, four incidents of retained objects after procedures, and one incident of administering medication via the wrong route.
The Trust had two Never Event incidents recorded in each of the two previous years, and Ms Wood says the sudden rise is a concern at a Trust where maternity services are under review after dozens of babies died or suffered injuries over 10 years, and where a recent Care Quality Commission (CQC) QC inspection found some midwives “may have been acting outside of their competency.”
“Any increase in Never Event cases is worrying and particularly perhaps in Nottingham where there has been such a sharp rise in a short space of time,” said Ms Wood.
“Ten cases may not seem hugely significant, but keep in mind that NHS England says a single incident should act as a red flag that an organisation’s systems may not be robust, and that lessons may need to be learned. A leap from two incidents to 10 is significant and calls for further investigation.”
Others to see cases on the rise include Manchester University NHS Trust, with 11 incidents over the past year including four cases of wrong site surgery, three incidents of retained foreign objects, two cases of nasal or gastric tubes being misplaced, one wrong implant procedure and one case of a patient falling from a poorly restricted window.
The Trust had previously reported 10 cases over the previous two-year periods.
Similarly, Sandwell and West Birmingham Hospitals NHS Trust has seen increases, from three cases three years ago to four last year, and then 10 in the latest set of provisional figures.
This included three cases of wrong-site surgery, three incidents where patients needing oxygen were wrongly connected to air, two cases of administering medicine by the wrong route, one case of a retained foreign object and one case of nasal or gastric tubes being misplaced.
Big improvers included Barts Health NHS Trust, with three cases in 2021-22 compared to 11 the year previous and 12 in 2019-20 and South Tees Hospitals NHS Foundation Trust, with eight incidents recorded for both of the last two years, falling to four in 2021-22.
