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Norfolk & Norwich University hospital, which is the largest hospital in the Norfolk region, has been told it must improve, following a visit by inspectors – a visit that was prompted by whistleblowers who were concerned with regular movements of staff between wards in order to cope with gaps in rotas, insufficient staff levels in key wards and allegations of bullying.
The report details a number of failings from the hospital, however perhaps most alarmingly the report highlights five never events (four involving surgical errors) within the trust between February 2016 and January 2017.
Never events are serious incidents that are wholly preventable but that have the potential to cause the patient serious injury or even death – although neither need happened for the incident to be classified as a never event.
Four of the never events were within the surgical services at the hospital. The report by the Care Quality Commission (CQC) details the surgical errors as below;
Two involved wrong-site surgery
One involved orthopaedic surgery where the wrong-sided implant was inserted
One related to inadequate tumour resection which resulted in a second surgery being required.
Following an investigation into each of these surgical mistakes, findings confirmed that theatre time out was not undertaken. Time out provides an additional opportunity for surgeons to take the time to review imagery, and confirm the correct side for surgery has been marked up on the consent form and that the theatre list is correct.
In addition, the report details how quality checks on the WHO surgical safety checklist were not being completed – a checklist which should be completed for every patient undergoing a surgical procedure.
In such extreme circumstances where mistakes and oversights from medical professionals and surgeons – such as operating on the wrong body part have directly impacted a patient’s recovery or wellbeing, patients may be entitled to compensation through pursuing a surgical error claim.
Insufficient staffing levels
In addition to the never events, the report also highlighted how staffing levels in the surgical wards often fell below the optimum. The CQC goes on to detail how there were a number of nursing vacancies, meaning shortages were often filled in by more junior members of the team. With medical teams stretched to their limits, there may be an increase in clinical negligence, leading to a greater number of patients forced to make medical negligence claims to assist them in covering costs of recovery and compensating them for loss, as well as unnecessary pain and suffering.
Impact of surgical errors on patient care
Surgery by its nature carries a certain element of risk, however, medical teams should take active steps to manage and control these risks. The report by the CQC highlights that surgical teams at Norfolk & Norwich University Hospital did not always actively follow guidelines and recommendations in order to minimise the impact of surgical procedures on patient care – such as infection control and quality checks. In such instances, there may be grounds for a hospital negligence claim as a result of poor care.
In response to the CQC report Mark Davies, Chief Executive of Norfolk & Norwich University Hospital stated:
“Our staff are amazing and the good progress we are making on our journey of improvement is because of their dedication and professionalism….Of course we recognise that there are areas that still require improvement and we are committed to working together with teams to make this happen.”