Surgeons at a London NHS trust left a pair of 9in forceps inside a patient after a major operation — with the blunder only discovered when she began to feel pain 10 days later.
In another case, surgeons almost transplanted the wrong kidney into a patient after a nurse handed them a donated organ intended for the next patient on their list.
Details of the incidents emerged last night when Guy’s and St Thomas’ — one of the best-regarded trusts in the NHS — went public with details of recent breaches of patient safety in a bid to promote transparency and learn from mistakes.
It reported 62 serious incidents and nine “never events” — blunders so serious they should never have happened — between April and November last year, the highest in the NHS. These include the death of a 12-year-old girl from a serious asthma attack and the discovery that a surgical swab had been left inside a woman undergoing a hysterectomy eight years earlier.
Leading doctors at the trust today called for an airline-style safety system to prevent surgeons being disturbed during operations as pilots are not disturbed in the cockpit.
Geoff Koffman, the chief of surgery at Guy’s and St Thomas’, told the trust board there had been 1,972 “near misses”, such as the near disaster during the kidney transplant, which had happened in the past six months at Guy’s, in London Bridge.
He said: “It wasn’t put into the patient. It was a near miss. We need to learn from these things.”
He told of another patient who underwent an extensive gynaecological operation that involved the removal of her spleen.
“The operation took many hours,” he said. “At the end of the operation the instruments and swabs were counted and the patient sent back to recovery. About 10 days after the operation she began to get abdominal pain.”
A CT scan showed a pair of Roberts forceps, about 9in long and similar in shape to household scissors, sitting vertically in her abdomen.
Mr Koffman said another gynaecological patient had a hysterectomy eight years ago. She was without pain until last year, when a laparotomy — the surgical opening of the abdomen — revealed a retained swab.
Rules in theatre have been changed to ensure the surgeon takes final responsibility for checking no objects have been left inside the patient.
Trust chairman Sir Hugh Taylor was “frustrated” to learn of the number of never events but said the hospitals were among those with the lowest mortality rates nationwide.
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