ONE of the country’s top children’s hospitals has taken full responsibility for wrongly removing a child’s healthy kidney during surgery.
An independent review at Our Lady’s Children’s Hospital, Crumlin, by London’s Great Ormond Street Hospital, looked into the events last spring when a child with a poorly-functioning right kidney was “incorrectly listed” by a consultant general surgeon for a left-sided kidney removal.
The operation was carried out the next day, after the parents gave consent, by a Specialist Registrar in paediatric surgery, who had not seen the patient.
The error was realised immediately after the healthy kidney was removed but , it was too late to correct.
According to the review, the mistake was made despite a concern being expressed by the parents about the side of surgery. This was conveyed by the ward nurse to the theatre nurse as the child was being transferred to the operating theatre.
The family, who wish to remain anonymous, confirmed that they raised concerns about the surgery, up to and including the time of the handover to theatre.
Our Lady’s yesterday said that these concerns were “not fully addressed” by the hospital at the time.
After the operation, the consultant was “open about the error, giving an immediate apology to the parents” and taking responsibility while the parents said that the care in the hospital since the incident had been “second to none.”
The review team identified 10 principal contributory factors, including:
An incorrect imaging report from six years earlier had not been identified and corrected.
No formal pre-surgery policy to ensure that the correct patient was having the correct procedure and on the correct side of the body.
Delays in adding hard copy x-ray reports to medical records.
No failsafe system to ensure a “multidisciplinary setting” for a patient undergoing removal of a major organ.
Patients regularly admitted outside normal working hours.
Radiology not sent to the ward or to theatre.
Formal consent taken by surgeons “not competent” to perform this procedure.
The hours and workload involved, and a lack of planning for cover.
Many of the clinicians interviewed said that the “heavy caseload” for the general surgery team, taken against the number of paediatric surgeons in the hospital, was a “root cause” of the error.
While it was outside the remit of the review to analyse the relationship between referral patterns, work practices and staffing levels in the department — “not least as this has a city-wide and national dimension” — the team did want to acknowledge “the prevalence of this view” among clinical staff.
Eight recommendations were in yesterday’s report, including:
Introducing “correct site hospital procedure” to ensure the correct procedure is carried out in the correct area during surgery.
A review of radiology systems at the hospital.
Formal diary monitoring of junior surgical working hours.
Team briefings at the outset of each surgical list.
Weekly planning meetings to agree cross-cover between doctors and plan elective work.
“Our Lady’s takes full responsibility for this tragic error and once again apologises most sincerely to the child and family,” said the hospital yesterday.
“The hospital continues to provide the family with support. The family has chosen to continue to have their child cared for at Our Lady’s.”
Any family concerned about the care received by their child at Our Lady’s is advised to contact the relevant clinical team.
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