Medics performed spinal procedure on wrong baby
Case is classed as wholly preventable hospital ‘never event’
A lumbar puncture was performed on the wrong baby at Tunbridge Wells Hospital, it has emerged.
Health chiefs are carrying out an investigation after the procedure - also known as a spinal tap - was carried out in February. It is performed by inserting a needle between two vertebrae to remove a sample of fluid and works to diagnose diseases of the central nervous system, including the brain and spine. Maidstone and Tunbridge Wells NHS Trust said two babies met the criteria for sepsis screening due to a history of maternal sepsis and the mother’s water breaking.
Both youngsters were taken to the neonatal unit from the postnatal ward to have bloods taken and checked for inflammation. Their parents were each told there may be a need for a spinal tap but results showed only one of them - Baby 1 - had raised inflammation markers, known as C-Reactive Protein (CRP), and would need the procedure. Generally, lumbar punctures are only considered when patients have CRP of 20, but Baby 2 was taken back to the neonatal unit and underwent the diagnostic test, despite having CRP of five. Hospital bosses said the child remained well and began taking antibiotics. Baby 1 had the spinal tap the following day and was not negatively affected by the delay. Ultimately, no harm occurred to either baby, the hospital insists, but it has been documented as a ‘never event’ patient safety incidents that are wholly preventable.
Staff are now asked to document their name cross-checks in medical notes.
A trust spokesman said further immediate actions would be taken, adding: “Patient safety is our absolute priority and we are carrying out a detailed investigation.
They added: “Never events are rare in our hospitals.”