Surgery blunder sees wrong side of 75-year-old patient's thyroid removed
Julia Gregory, Local Democracy Reporter
- Credit: Fin Fahey
The wrong side of a patient’s thyroid was removed during surgery at Homerton Hospital, triggering an investigation.
The "never event" was revealed in Homerton University Foundation Trust’s latest quality report, which looks into care at the hospital including serious incidents.
Serious incidents between April and June include a 75-year-old needing surgery after falling in a ward, and delays in the diagnosis and treatment of a 37-year-old with necrotising fasciitis, a rare but serious bacterial infection.
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.
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The mistake was spotted as the tissues were being labelled and medics decided to remove the whole thyroid.
This was classed as a "never event" and triggered a serious incident review.
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Staff have looked into the way the site to be removed was marked and have suggested changing pens to avoid a similar incident.
There were three never events at the Homerton last year, and seven serious incidents.
These include two infection control outbreaks and Covid outbreaks during the second wave of the pandemic.
Investigators also looked into the sudden deaths of a three-day-old baby with strep sepsis and a 40-year-old man who had ENT (ear, nose and throat) surgery.
During the first three months of 2021/22, 238 incidents of concern were recorded.
Report author Chief Nurse Catherine Pelley said the incidents included 52 cases of patients not following the recommended treatment; 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 it should share more widely with patients and their families details of “enduring improvement to access, safety and quality of services, and advances made in learning from incidents, complaints and investigations”.
The trust said it “will explore further opportunities to improve how we share the improvements and advances made in learning from incidents, complaints, and investigations”.