Shropshire Star

Shropshire medics operate on wrong part of patient's spine

A spinal patient at a Shropshire hospital underwent surgery on the wrong part of their spine.

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The incident, classed as a 'never event' because, as the name suggests, it is something that should never happen, occurred at Oswestry's orthopaedic hospital in October and was reported to its board of directors yesterday.

Surgeons operated on the patient, who has not been identified, at the "wrong level" meaning at the wrong vertebra of the spine.

The incident has prompted an investigation at the hospital, with surgeons being asked to consider what could be done to prevent any recurrence of this type of mistake.

Steve White, medical director at the The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, said a similar incident had happened before, but not for several years.

He told the meeting: "Unfortunately there has been a serious incident and a never event in which a patient has undergone spinal surgery at the wrong level."

He said the last time there had been a never event a standard operating procedure was put together, which was employed in this case.

He added: "We're now going to have to review that again."

Mr White said all relevant authorities have been notified about the incident and it is currently being investigated and it will also be reported to the Quality and Safety Committee.

Jayne Downey, director of nursing and service delivery, said: "I can confirm that the incident is being fully investigated, and in fact the patient has been fully involved in the investigation process to aid the trust's understanding of the incident. The outcome of the investigation will be shared with the trust board, and used to inform changes to practices in the future.

"The patient has been discharged and is recovering as expected."

A previous never event occurred at the hospital in November 2011 when a patient was fitted with the wrong part during a knee replacement operation, partly because staff could not read a label properly.

The incident was reported to the manufacturer and the part's labelling was changed as a result.

Meanwhile, the hospital trust has been named the best in the UK for its food and cleanliness following a survey of 600 patients.

The CQC in-patient survey was carried out at the orthopaedic hospital with patients who had been treated at the hospital last year.

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