Do Yourself a Favour

In April 2008, a young boy was admitted to the country’s leading Children’s Hospital, to undergo surgery to have his defective right kidney removed. It later emerged that his healthy left kidney had been removed 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 inquiry is now under way into allegations of professional misconduct against two doctors over the removal of the wrong kidney.

The parents of the 6 year old boy attended the fitness to practice inquiry last week, to tell their story in the hope that it would help to prevent this tragedy occurring again. The mother told the inquiry that her son was referred to the hospital for treatment following recurrent kidney infections. An ultrasound scan had revealed that the child’s left kidney was functioning normally while his right kidney was small, with only 9 percent function. The mother was told by the consultant surgeon at the hospital that her son would need his poorly functioning right kidney removed but then the surgeon incorrectly noted in the hospital chart that the left kidney was the one to be removed. This was the first in a series of errors which unfortunately led to the wrong kidney being removed.

The first the parents knew of the wrong kidney being listed for surgery, was when consent was sought for the operation. The parents have told the inquiry that while they felt embarrassed for questioning if the doctors were right, they persisted in asking hospital staff to double check their facts. A hospital spokesperson has confirmed that the parents repeatedly raised concerns and questioned if the correct kidney was being removed, up to and including the time of handover to the operating theatre.

This tragic case is not only every parent’s nightmare, it’s probably every doctor’s nightmare as well. It raises many important questions about the issue of doctors working under too much pressure in a hospital system that is stretched to the limits. The concerns voiced by this child’s parents, should have been enough to alert hospital staff to the fact that something was wrong. Has our health service really become so automated, impersonal and intimidating that parent’s/patient’s concerns don’t count any more? Surely, if any parent raises a concern about their child’s treatment, they deserve to have their concerns properly addressed before being expected to hand over the care of their child?

If one lesson is to be learnt from this terrible tragedy, it is that we as parents/patients should never hesitate to question medical care especially when something doesn’t add up.

We could be doing ourselves a real favour. The hearing is due to continue in September.

RTE News – Thursday, 27 May 2010

4 Responses to Do Yourself a Favour

  1. Nancy says:

    Hi Steph,

    What a sad state of affairs this is.It is bad enough when an error is made on an older person, but to do this much harm to a young boy is unforgivable. He will have to live the rest of his life with the consequences. Thank God for kidney transplants. He has a chance there.

    This type of error happens here,too. A friend of mine was having a mastectomy. Her right breast was scheduled for removal and my friend was worried about a mishap like this happening. SO, she and her friends got colored ink pens and drew circles and arrows pointing to the left breast with the words saying “DO NOT REMOVE” and “WRONG BREAST” and all sorts of funny remarks. But, the truth is, they didn’t do it to be funny; they were really afraid of a terrible mistake, but not wanting to antagonize the doctor they tried to make a joke off it. You know the old saying “Half fun and all earnest”

    All turned out well. They removed the right breast and my friend is half convinced she had a part in making that happen….

    • Steph says:

      Nancy – Apparently, this young boy has managed much better than expected with his one remaining defective kidney and has not required dialysis so far.

      My own daughter had chronic kidney disease as a child which required corrective surgery on one side only when she was eight.

      As a result, I can well imagine the stress and confusion that this boy’s parents must have suffered when they discovered that their son was listed for surgery on the opposite side to what they’d originally been told. The bit I can’t comprehend however, is that the surgery went ahead despite the concerns raised by the boy’s parents.

      I’m glad that your friend had the good sense to ensure that there was no mix-up with her surgery. I’m a great believer in employing humour (when appropriate) to relieve tense medical situations. I have been known to wear a red nose when being wheeled into theatre for nasal surgery. Well, it was red nose day!

  2. Annb says:

    As a parent of a child with a complicated kidney history, I was not at all surprised when I heard this story because of the hospital in question. I spent the first year of my son’s life in this hospital which at that time, did not have a dedicated renal ward. Meanwhile, other side of town there was a dedicated national renal unit, which nobody told us about. I had frequent concerns over my son’s care in this hospital because of chronic overcrowding. I had reason to contact hospital management many times over basic health and safety issues – I was repeatedly fobbed off with patronizing replies and denials. It was only when I had a question raised in the Dail that management started to listen, however this coincided with my son’s transfer, for medical reasons, to the renal unit across town. I have repeatedly asked why renal patients are seen in this hospital and have yet to get an answer. I still attend that hospital from time to time – I always bring another adult with me and I double check every chart, medication and feed. Every surgery we’ve had there has reduced me to a terrified wreck.

    I am eternally grateful to the parents of this young boy, who at a time of unimaginable heartache and stress, have taken the time to speak out in order to protect the future well being of my child. It is only when patients speak up in the right forum that we see change, it’s just a tragedy that a young child will now needlessly be put through the trauma of dialysis and transplant. And I’ll bet the family get precious little support from the community health services during this ordeal.

    Sorry for the rant Steph but this is obviously a sore point with me – thank you for raising it.

  3. Steph says:

    Annb – I love it when you rant as it means that those who have little experience of hospitals, get to hear the real story.

    I suspect that the answer to your question about the location of treatment for paediatric renal patients, has more to do with the consultant’s ego than with your son’s welfare.

    The independent report issued on the ‘wrong kidney’ case made eight recommendations to ensure that the mistake is never repeated. I hope after the Medical Council’s inquiry is completed that in future, parental concerns will be given the respect they deserve. It’s all very well improving hospital procedures but if parent’s concerns aren’t properly addressed, then accidents like this are more likely to happen.

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