Hospital makes same surgery error three times

Lesions were incorrectly removed from three patients, but the hospital is yet to establish what led to the errors

A hospital has carried out three wrong-site surgeries in as many months, and bosses have yet to determine why it keeps happening.

The three "never events" at the Royal Stoke University Hospital involved incorrect lesions and scars being removed from patients during surgery.

After the second incident in February, the hospital looked to see what lessons could be learned to stop it happening again, but a third wrong-site surgery was carried out in March.

A thematic review of the three mistakes is now being carried out, which will make recommendations on how processes could be improved to reduce the risk of future incidents.

A report on the latest wrong-site surgery states a patient attended an appointment in February, following a referral for a lesion on his scalp.

But during the appointment, the doctor reviewed a old referral from 2021 which was in relation to a lesion on the patient’s neck, which had been treated at the time.

This resulted in the patient undergoing a punch biopsy on his neck in March, with the mistake coming to light the next day when his daughter raised concerns the wrong lesion had been operated on.

Further work

The first incident to be reported took place in January, when a patient had a scar removed at the dermatology department.

It was subsequently found that the surgeon had operated on an old scar from an excision the patient had in 2017.

Another wrong-site surgery involving an incorrect lesion was carried out on January, but was only reported after the patient was discharged from hospital the following month.

Chief nurse Anne-Marie Riley told a meeting of the University Hospital of North Midlands trust board that further work was being carried out to address the issue.

She said: "After the second incident, they believed at that point they had put in every intervention across the board that would prevent this happening again, but clearly it didn’t."

Every option, internally and externally, would be looked at again, she said.

"The team did a really intensive piece of work, looking at very specific checkpoints to stop this happening again, but clearly something has failed, and we need to understand why."

This news was gathered by the Local Democracy Reporting Service which covers councils and other public service organisations.