Surgical instrument left in stomach

02:12, Nov 21 2012

A surgical instrument left in a patient's stomach, a baby who died following an emergency caesarean and a mental health patient killed after being hit by a car while running away from care are among serious incidents reports by Canterbury's hospitals in the last year.

The Canterbury District Health Board's (CDHB) Serious and Sentinel Events (SSE) report for the year ending June 30 was released today, with 49 events reported - the same number as the previous year, and 20 fewer than the year ending June 2010.

A serious adverse event is one that leads to significant additional treatment, while a sentinel adverse event is considered life-threatening or has led to an unexpected death or major loss of function.

The report included three suspected suicides of inpatients, including one involved an inpatient on arranged home leave.

Other incidents included a swab left in a patient's body after surgery and a surgical instrument left in a patient's abdominal cavity at the end of surgery.

A review into the first incident was under way, but the second was found to have been caused by ambiguity in the hospital's surgical count policy.


Six serious and sentinel events relating to pregnancies or births were also reported by the CDHB.

One incident included a baby dying after an emergency caesarean for placental abruption. The review team found the time taken to complete an ultrasound may have contributed to the baby's death.

Other incidents included a patient miscarrying after a misdiagnosed ectopic pregnancy and a baby left with a possible brain injury during a difficult delivery.

About six of the reported events related to mental health patients, including one who ran away from a mental health facility and was hit by a vehicle. The patient later died from their injuries, but a review team did not find any definitive systems failures that contributed to the patient's death.

Two other mental health patients also absconded in the year to June 30, but returned without incident.

A mental health outpatient was charged with murder, and a review into the incident was still ongoing.

In another incident a mental patient was charged with attempted murder. The board's report said elements of the patient's documentation had not been fully completed.

The furnishings layout and security arrangements in the room used for Mental Health Act hearings was also found to have contributed to a mental health patient being involved in an assault.

A review recommended changing the physical size, layout and furnishing of the room, as well as reviewing the security arrangements. The recommendations had since been carried out.

The CDHB also recorded 22 serious and sentinel falls, with most resulting in cuts or fractured hips. One patient suffered a fractured hip and died the following day before being stable enough for surgery.

The report said the board was focused on raising awareness of falls prevention and had been reviewing its current practices.

CDHB chief medical officer Dr Nigel Millar said in a statement that there was no acceptable number of serious or sentinel adverse events.

''These incidents occur when people are let down by the system, which exists to protect them.

"The CDHB must always do everything possible to reduce the chance of the same thing happening to another patient. When people are harmed in our care we must respect their experience through being open and honest about what has happened."

He was encouraged to see the board's effort to reduce falls was working, with serious harm from falls reduced by 40 per cent in the last year.

"Achieving our goal of zero harm from falls, as well as preventing any sort of harm to patients both in a hospital or community setting, is going to take perseverance - not only from our staff but from everyone - the responsibility is shared by us all."

CDHB chief executive David Meates said staff were always encouraged to report all incidents as the system ''cannot improve if we don't learn from our mistakes''.

"It's about having those difficult conversations. Apologising to patients and families when someone has been harmed or has died as a result of a failure in our ability to provide appropriate care is one of the toughest conversations a clinician or manager will have, but it's the least we can do."


Meanwhile, four serious and sentinel events were reported by the West Coast District Health Board (WCDHB) in the year ending June 30.

One involved a patient who received burns during surgery. The incident was still under investigation.

WCDHB chief medical officer Dr Carol Atmore said the other three incidents were potentially serious, but did not result in harm.

One involved the resuscitation of a baby in Greymouth Hospital's maternity ward. Staff were congratulated on a successful outcome, but the review team recommended using the emergency department for resuscitation.

The other two incidents included a patient threatening a staff member and an attempted assault on staff. Atmore said it could be traumatic for patients to be harmed while receiving medical care.

''Incident reporting and the investigation process that follows is key to reducing the likelihood of it ever recurring.''

The Press