A Terrible Blunder

October 23, 2008

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.