The wrong side of a patient’s thyroid was removed during surgery at the Homerton Hospital, triggering an investigation into what went wrong.
The “Never Event” incident was revealed in Homerton University Foundation Trust’s latest quality report, which looks into care at the hospital including Never Events and serious incidents.
Never Events are “serious incidents that are entirely preventable“.
The serious incidents between April and June include a 75-year-old needing surgery after a fracture when they fell in a ward and a 37-year-old with necrotising fasciitis, a rare but serious bacterial infection which is also known as “flesh-eating disease” – although the bacteria release toxins that damage nearby tissue and do not eat it, there were delays in the patient’s diagnosis and treatment.
One patient consented to having a left hemithyroidectomy – removal of part of the thyroid in the neck – but the right side was removed instead.
Surgery can be needed because of problems with breathing or swallowing, thyroid cancer, a recurring thyroid cyst, a benign tumour or Grave’s disease, according to the British Thyroid Foundation.
The mistake was spotted as the tissues were being labelled and medics decided to remove the whole thyroid.
This meant the patient had to undergo a total thyroidectomy.
This was classed as a Never Event and triggered a serious incident review.
Staff have looked into the way the site to be removed was marked and have suggested changing pens to avoid a similar incident. Medics are also sharing what they learnt with the World Health Organisation.
There were three Never Events at the Homerton last year.
Staff also investigated seven serious incidents.
These include two infection control outbreaks and the Covid outbreaks during the second wave of the pandemic.
Investigators also looked into the sudden deaths of two patients – a three-day-old baby with strep sepsis and a 40-year-old man who had ENT surgery.
Another case was that of a 60-year-old man whose pressure sore deteriorated whilst he was an inpatient at the Homerton.
The trust’s top five areas of concern during the first three months of 2021/22 were pressure ulcers patients were suffering from before arriving at the Homerton; treatments or procedures, with 238 incidents recorded; pressure ulcers or skin damage they got at the Homerton; violence, abuse or aggression towards staff; and patients falling.
Report author Chief Nurse Catherine Pelley explained that these incidents included 52 cases of patients not following the recommended treatment – the majority were being cared for by community nurses – 49 cases of delays, cancelled or postponed treatment, and 48 cases of inadequate treatment or care, with one case causing severe harm to the patient.
Healthwatch Hackney told the trust that it should share details of “enduring improvement to access, safety and quality of services, and advances made in learning from incidents, complaints and investigations” more widely with patients and their families.
The trust responded that it “will explore further opportunities to improve how we share the improvements and advances made in learning from incidents, complaints, and investigations”.