A Terrible Blunder

Last April a young boy was admitted to Crumlin Children’s Hospital in Dublin, to undergo surgery to have his defective right kidney removed. It later emerged that his healthy left kidney had been removed in error. Today a report has been released following an independent investigation into the tragedy and it’s revealed a shocking catalogue of contributing factors which led to the mistake.  It was described as “an accident waiting to happen”.

When news first broke of this medical blunder, it seemed incredulous that such a terrible mistake could occur at the country’s leading children’s hospital. It has now transpired that the consultant general surgeon who recommended the surgery, mistakenly listed the wrong kidney on the surgical request form.  When the child was admitted to the hospital, a junior doctor filled out a consent form for the parents to sign without referring to the clinical notes on the child and again the wrong kidney was listed for removal. The child’s operation was carried out by a senior surgical registrar who had not examined the child on the ward before he was brought to theatre. This surgeon proceeded to remove a perfectly healthy left kidney leaving the unfortunate child with one poorly functioning right kidney.

The investigation carried out by experts at London’s renowned Great Ormond Street Hospital, outlined ten contributing factors to the botched surgery. These included delays in filing hard copy x-ray reports in the medical records, patients being regularly admitted outside of working hours and the heavy workload of doctors at the hospital. The report found that there was no policy in place at the hospital to mark the site of the procedure and that the surgeon didn’t have access to scans for reference at the time of the surgery. It also found that there was no fail-safe system to ensure a patient having surgery had their case discussed by a range of experts. It said the operation was carried out by a paediatric surgeon who hadn’t met the patient beforehand and when the blunder became obvious, it was too late to do anything about it. The report made eight recommendations to ensure the mistake is not repeated, including:

* The hospital should formally monitor the hours junior doctors work. Overwork was stated as a contributory factor in the error over the consent form. It’s a well-known fact that junior doctors are expected to work horrendously long hours resulting in serious sleep deprivation and it’s inevitable that mistakes will occur if their workload is not properly regulated or supervised.

* Surgeons should introduce team briefings at the outset of each theatre list to discuss patients. The surgeons at Crumlin Hospital have an enormous workload and are working under huge pressure to reduce long waiting lists.

* Radiology and x-ray systems should be reviewed. No up-to-date scan was available on the child for reference during the surgery.

* Consent processes should be revised. A hospital spokesperson admitted that the family had repeatedly raised concerns and questioned if the correct kidney was being removed, up to and including the time of handover to theatre.

This tragic case will undoubtedly raise concerns for the parents of any child who is presently awaiting surgery. The report has clearly outlined the need for extra safety measures to be implemented for children undergoing surgery. It has also raised the issue of doctors working under too much pressure in a hospital system that is stretched to the limits. Thankfully, the hospital appears to have handled the situation correctly as it’s taken full responsibility for the tragic error and has offered an apology. The child’s parents are happy for the child to continue to receive treatment at the hospital and have requested anonymity. One can only hope that the child will be a suitable recipient for a kidney transplant in the future and that lessons will have been learnt to prevent a tragedy like this ever occurring again.

6 Responses to A Terrible Blunder

  1. Madsadgirl says:

    A truly horrendous story. This is a good example of why there needs to be proper contact between doctors and the patients and their families, and why doctors should not be expected to work excessive hours.

    (Picture now posted)

  2. Grannymar says:

    I echo your words Steph, that the child will be looked after in the correct way and find a suitable kidney very soon.

    I remember going for a D&C years ago and being fascinated by the fact that instructions were written on my thigh. I was asked, and repeated to all but the cat why I was in hospital and what procedure I was about to have.

    The reason for the diligence was that a young lady also a candidate for D&C, returned from theatre one week before having had a full hysterectomy!

  3. What a tragic story – and so easily preventable. It seems that medical blunders like this crop up all over, fortunately not frequently. But you’d think that one such blunder would be enough for it to never happen again, anywhere.

    I recall visiting my mum when she was in hospital a few years ago. There was a sudden bellow from down the passage and man’s voice screamed, “What the *&($# have you done to me!” There was the sound of feet pounding down the corridor and I turned and said to my mother, “you know what, what’s the bet they were supposed to take off his left leg and have instead taken off the right one.” Never did find out what happened, decided there were some things I’d rather not know about.

  4. Bendy Girl says:

    How tragic, I remember a very similar case (but on an adult) in Wales I think a few years back where the wrong kidney was removed. Having had lots of shoulder surgeries I can see how easily this could happen, I was marked up incorrectly by one registrar who despite checking the notes (which were correct) still made the mistake.

    The one positive in this tale is that the hospital have taken full responsibility. I firmly believe a no fault compensation system would improve things for patients and medical staff.
    Hope you’re well Steph, BG x x x

  5. Steph says:

    Thanks to all for your comments on this sad story.

    MSG – The report says the child’s consultant had planned to have multidisciplinary discussions before surgery but it didn’t happen. Often patients are admitted outside normal working hours on the day before surgery, which leaves little chance for their review before surgery. You can see how this child slipped through the safety net.

    Grannymar – I find it incredible that a hospital and especially a children’s hospital, had no site-marking policy to eliminate the risk of wrong-side surgery. I would have thought that it was normal practice in every hospital and absolutely mandatory where children are involved.

    AV – To make matters worse, the same hospital had a ‘near-miss’ 7 years ago when a patient booked to have a left-sided procedure had a right-sided incision made!

    The specialist registrar who performed the surgery, was asked by the consultant if he would like to do the case when he turned up in theatre to assist on the day. The kidney removal (nephrectomy) was within the competence of this doctor although he had never performed one completely unsupervised, and was handed the case at short notice. The child was already anaesthetised and the registrar operated unsupervised. You can clearly see how this was an ‘accident waiting to happen’. The consultant must shoulder the blame for not supervising the procedure.

    BG – No X-ray images were reviewed prior to or during surgery even when it was noted the kidney being removed looked healthy. When the wrong kidney was removed from this child, the error was realised immediately but it was not possible to put it back. As you say, it’s a relief that the hospital has admitted full liability and apologised but really nothing will ever compensate for something that was so preventable and should never have happened.

    Another worrying factor to come out of this investigation was the staff reporting that they felt their workload was a root cause of what happened. There had been an increase in referrals to this hospital without extra staff. Junior surgical doctors worked on average 73 hours a week when not on call and 107 hours a week when on call between January and April this year. Theatres were so busy, staff reported the average turnaround time between patients was two minutes.

    Is it any wonder that mistakes occur when people’s lives are put at risk with this ‘conveyor belt’ style of medicine!

  6. […] in error. An independent review of the case, identified 10 contributory factors which led to this terrible blunder. It was described as “an accident waiting to happen”. A medical council fitness to practice […]

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