Piece of a screw left in woman’s foot following operation at Gorleston hospital
PUBLISHED: 16:26 28 July 2017 | UPDATED: 16:47 28 July 2017
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An investigation has been launched by a hospital after a piece of a screw was left inside the toe of a patient.
It happened on June 5 at the James Paget University Hospital (JPUH) where a woman had an operation on her foot.
But x-ray checks taken afterwards showed a small piece of a screw had been left in the soft tissue of the patient’s toe.
The incident was categorised as a “never event” - an error so serious it should never happen.
A never event is deemed to have been preventable and has the potential to cause serious harm.
In this case, the woman was not harmed, but another surgery may be required to remove the piece of screw.
JPUH director of governance, Anna Hill, said: “The patient was informed of what had happened by the operating surgeon and she continues to be monitored by the team.
“An investigation is underway into what happened and we have been keeping the patient informed throughout the process.
“The James Paget University Hospital is a learning organisation and enhanced and additional checks have been put in place as a result of this event.”
When presenting the quality and safety report at the JPH’s board of directors meeting on Friday, July 28, medical director Nick Oligbo informed trust members of the incident.
He said: “Unfortunately we have had one ‘never event’ in June. It was an orthopaedic event where a piece of the instrument used was left behind. It was designed to be detached and we are now having a full analysis.
“The lessons we need to learn will be shared with the board.”
The incident is the first never event at the hospital in 2017/18 and the first JPUH has experienced since September 2016.
However, it is one of three serious incidents recorded at the hospital in June.
Mr Oligbo reported that two patients also suffered a “fractured neck of femur”. The femur, or thigh bone, is one of the largest and strongest bones in the body.
A fractured neck of femur is when the top part of this bone is broken and usually requires surgery to amend.
The first incident happened on Sunday, June 4 and resulted from a “slip or trip”. The second on Monday, June 12 was the result of a patient falling while walking.
The report also revealed that no cases of hospital-acquired MRSA bacteraemia or surgical site infections had been reported this year, leaving the board to conclude that June had been “a mixed month”.