SURGERY WHICH resulted in a child having the wrong kidney removed at Our Lady's Hospital for Sick Children in Crumlin, Dublin, proceeded despite concerns being raised by the child's parents about the side of the body on which the operation was being performed, an independent investigation has found, writes Eithne Donnellan, Health Correspondent.
It also found a whole series of factors resulted in the child having a healthy kidney removed last spring, to be left with a poorly functioning one.
There were no X-ray images reviewed at several stages in the process: when the child was listed for surgery in outpatients; when the child was admitted to hospital the day before surgery; on the pre-operative morning ward round on the day of surgery; in response to queries from parents about the operation side; or in theatre prior to making the incision.
Neither were the X-rays reviewed during the operation when the kidney had a healthy appearance.
And the hospital had no "site-marking" policy to eliminate the risk of wrong-side surgery despite a "near miss" incident seven years earlier when a patient booked to have a left-sided procedure had a right-sided incision made.
That error was noted at an early point and the correct procedure was performed. After that, the general surgical team agreed the site of surgery should be marked. But this obviously didn't always happen.
The independent report, carried out by a team from Great Ormond Street Hospital in London, found the child was incorrectly listed by a consultant general surgeon for a left-sided kidney removal after attending outpatients.
When the child was admitted to hospital for the operation, the procedure was carried out by a specialist registrar in paediatric surgery "who had not seen the patient previously". This registrar was asked by the consultant if he would like to do the case when he turned up in theatre to assist on the day.
"A nephrectomy [kidney removal] was within the competence of the specialist registrar although he had never performed one completely unsupervised, and was handed the case at short notice," the report said. The child was already anaesthetised and the registrar operated unsupervised.
The report says that when the healthy kidney was removed, the error was realised immediately but it was not possible to re-insert the organ. The child, who remains anonymous, continues to attend the hospital and the child's parents told the review team the care since has been "second to none".
The review team found the child's parents had expressed concern in advance about the side of the surgery. "On transfer to theatre, the ward nurse handed over to the receiving nurse a concern expressed by the parents about the side of surgery," the report says. It adds that the receiving nurse contacted her manager and the registrar talked to the parents.
In a statement yesterday, the hospital said the family did raise concerns about their child's surgery, on a number of occasions, up to and including the time of handover to theatre.
"These concerns were not fully addressed by the hospital and Our Lady's takes full responsibility for this tragic error," it said.
The investigation team identified 10 principal contributory factors to the error.
These included the fact that: the hospital has no site-marking policy to eliminate the risk of wrong-side surgery; an incorrect imaging report from six years earlier had not been identified and corrected; there were delays in filing hard-copy X-ray reports in medical records - one of the child's X-ray reports "had been lost for six months" in the period between the X-ray and admission for surgery; and there was no fail-safe system to ensure a patient undergoing removal of a major organ was discussed in a multidisciplinary setting.
The report says the child's consultant had planned to have multidisciplinary discussions before surgery but it didn't happen, partly because the operation date was brought forward by approximately three months.
It also says staff felt workload was a root cause of what happened. There had been an increase in referrals without extra staff.
Eight recommendations were made by the inquiry team.
It said the hospital should introduce a correct site surgery policy; there should be formal monitoring of junior doctors' surgical hours; the hospital should review its radiology systems; and there should be team briefings at the outset of each theatre list.
The hospital has apologised for the error and says it will implement all the recommendations.
Reasons for error: contributing errors
•A consultant general surgeon wrongly listed a child with a poorly functioning right kidney for a left-sided nephrectomy (kidney removal) after seeing the child in outpatients.
•Concern was expressed by the child's parents about the side of surgery before the child was taken to theatre.
•The operation, removing the wrong kidney, was carried out by a specialist registrar in paediatric surgery who had not seen the patient previously.
•No X-ray images were reviewed prior to or during surgery even when it was noted the kidney being removed looked healthy.
•At the time of the incident Our Lady's Hospital for Sick Children had no formal or universal process to confirm that the correct patient was having the correct procedure, and on the correct side.
•When the wrong kidney was removed from this child the error was realised immediately but it was not possible to put it back.
•Staff felt their workload was a root cause of what happened. There had been an increase in referrals to the hospital without extra staff. Junior surgical doctors worked on average 73 hours a week when not on call and 107 hours a week when on call between January and April this year.
•Often patients are admitted outside normal working hours on the day before surgery, which leaves little chance for their review before surgery.
•Theatres were so busy staff reported the average turnaround time between patients was two minutes.