A Freedom of Information request has revealed a number of errors by medical staff in the hospital network in Limerick. GORDON DEEGANreports
AN OPERATION on the “wrong” side of a patient’s body was averted only after the patient alerted medical staff to the mistake on the way to theatre.
The error is just one of a series of mistakes by medical staff revealed today in documents released by the Health Service Executive (HSE) through the Freedom of Information Act concerning the hospital network in Limerick.
The 86 complaints received in the second half of last year relate to patient care and they include:
- one elderly man wetting and soiling himself at the Limerick Regional Hospital's overcrowded AE due to the stress of enduring a "nightmare" 26 hours on a trolley;
- a cancer survivor who was refused a mammogram at Limerick's Breast Clinic and made "to feel like a hypochondriac" by staff;
- a staple left in a female patient's skin over four weeks after an operation that left her sore, depressed and very upset, and was only discovered by her GP;
- a broken leg missed twice by medical personnel in separate X-rays, resulting in the patient suffering unnecessary trauma and pain; and
- a broken foot not detected and patient made to feel like "a time waster".
In response to the patient’s complaint over medical personnel about to operate on the left rather than right hand side of the body at Limerick Regional Hospital, the HSE stated that after the error was pointed out to the nurse “all checks had worked effectively”.
Fine Gael health spokesman, Dr James Reilly, said yesterday: “Human error will always be with us and a good health system reduces the chance of mistakes happening, but we don’t have a good health system.”
Calling for a Patient Safety Authority, Dr Reilly said: “The mistake of almost operating on the wrong side of a patient’s body is a serious one and is deeply worrying, and a system of double checking needs to be put in place to prevent this happening.”
Labour Health spokeswoman and Limerick East TD, Jan O’Sullivan, said yesterday: “My view is that the mistakes are due to the huge pressures on staff and a lack of resources in the health system.”
Last year, Limerick Regional’s AE dealt with 59,346 “emergency presentations”, while Croom Hospital dealt with 2,625 day cases. A HSE spokesman said yesterday: “Our objective is to ensure that every patient has a good experience when they enter our hospital, but we have to recognise that given the complexities of healthcare and human factors this is not always the case.
“The number of complaints is low when taken in the context of overall hospital activity. Every one is taken seriously and complaints form part of the learning process for all staff.”
Against the background of Limerick Regional Hospital taking on additional work with the closure of the 24-hour AE at Ennis and Nenagh General Hospitals, HSE West member, Cllr Brian Meaney (Green), said: “It is a concern that these incidents could become more prevalent due to the pressure and strain that will come on Limerick in the future, due to the plans for it outlined in the review of acute services in the midwest.”
- THE ASTERIKS in the following case studies are blacked out or redacted information.
Case study – Patient averted operation on wrong side of body on way to theatre.
‘I BECAME concerned when a nurse remarked to me as I was wheeled to theatre that my *** was to be operated on.
“I pointed out that this was incorrect. The nurse made no correction to the notes, nor did the nurse take any other action.
“I asked the anaesthetist to look at the notes before I was brought into the theatre. The anaesthetist also read the notes as indicating that the left side was to be operated .
“I mentioned to the anaesthetist that the *** was in my right *** and the notes were corrected.
“In the doctor’s notes, the side on which I was to be operated was indicated by a single letter. It looked like the letter L to the nurse and anaesthetist. The letter was subsequently replaced with the word ‘RIGHT’ by the anaesthetist on my request.
“Had I not intervened minutes before the operation myself I would have gone to theatre with notes indicating the incorrect side for the operation.
“While I came quite close to suffering a significant inconvenience, I didn’t make a complaint at the time. However, in light of recent cases where similar mix-ups have had devastating results, I now feel obliged to tell you.”
In the response, the HSE complaints officer stated “the nurse on duty was alerted to the error on escorting you to theatre. She brought the error to the attention of theatre staff and Mr ****’s Team. Therefore, it would appear that all checks worked effectively and that the error made on the consent form was rectified quickly.”
Case study – Elderly man suffers “nightmare” 26 hours on trolley in Limerick AE, resulting in him wetting and soiling himself.
THE MAN was a patient receiving respite care at St Camillus’s Hospital when he contracted a suspected chest infection and was sent to Limerick Regional’s AE.
According to a relative’s complaint letter: “There, he endured what I can only describe as the nightmare of spending 26 hours on a trolley in the hectic AE department while waiting to be admitted to a hospital bed.
“He became hemmed in, in unfamiliar, strange and hectic surroundings, and he became increasingly distressed and uncomfortable. As there was no room to be near him and as he seemed to be sleeping, we left him at midnight. I returned the following morning at 7am to find him in the same spot, only even more hemmed in.
“The nurse nearby explained to me that, during the night, he had woken a few times, had wet himself and she put a pad on him. She asked if he was normally incontinent. I explained that he was not and never had been.
“I told the staff that the surroundings and conditions were totally unsuitable to his needs. On his way to the toilet at 9.30am, he wet and soiled himself to his great indignity and embarrassment. I explained what had happened and asked that he be cleaned.
“I was told that I was being too demanding and that they would help him when free to do so. Only after creating a small scene, which I was most uncomfortable with, did they remove him to an area where he could be cleaned up and made comfortable. It was a most distressing and degrading experience.”