Shocking toll of errors that puts NHS patients’ lives in danger

PATIENTS are suffering potentially fatal harm because NHS staff are making basic mistakes such as failing to read their medical notes, according to internal health service documents.

Doctors are performing surgery on the wrong part of the body, or giving the wrong type of blood, because they are paying scant attention to notes, not checking the identities of their patients, or working by themselves. Such errors are called ‘never events’ by the NHS because they simply should not happen.

However, one such incident occurs somewhere in England almost every day, according to official figures – which, although made public, rarely provide any explanations.

Now, though, The Mail on Sunday, using the Freedom of Information Act, has unearthed detailed reasons for a number of recent ‘never events’. These include two occasions on which patients were given the incorrect blood type, which can prove fatal.

In July 2015, one such mistake happened because a doctor had used a transfusion from the wrong patient. A note explaining the incident read: ‘Incompatible red [blood] cells were transfused to a patient due to a pretransfusion sampling error where the blood was collected by the doctor from the wrong patient because the required patient identification checks were not completed.’

And last November, a poorly baby received the wrong blood because of an error by a ‘lone working’ member of staff ‘in the heat of an ongoing emergency’. It is unclear whether the two patients lived or died.

Another blunder led to a patient having a tendon operation performed on the wrong toe because staff failed to read the medical notes correctly.

According to subsequent analysis of the incident, the locum surgeon ‘did not have any doubt’ which toe was to be operated on – but was mistaken. The notes blamed the error on how busy the clinic was. A similar incident led to someone undergoing angioplasty, a procedure to clear blood vessels, performed on the wrong part of the body. Doctors realised they had ‘mis-read the request card’ afterwards and performed the correct operation later.

And in March this year, a patient who had been due to undergo a colonoscopy, where a tiny camera is inserted up the anal passage to check for bowel problems, was given a gastroscopy instead. This is a procedure during which a camera is inserted down the throat, to look for problems in the upper part of the digestive system.

Katherine Murphy, chief executive of The Patients Association, said it should be made clear to all staff and medical professionals ‘that to simply forget or not take due care and attention is wholly unacceptable’.

A spokesman for NHS Improvement said: ‘We will continue to share the learning from incidents and help providers prevent them from happening again so patients get the safe and quality care they expect.’