Lying on an operating table after a suspected heart attack in July last year, David Fortes struggled to take on board what his consultant was telling him.
The 75-year-old retired painter and decorator had just had an angiogram — where dye is injected into the bloodstream during an X-ray.
The team were checking for a blocked artery but didn’t find any. Nor did they find any sign that David had suffered a heart attack.
But what they did find was a wire over a foot long buried inside his arm, running up to his shoulder and into his neck then down into his chest.
David, who was sedated but conscious for the treatment, recalls the cardiologist stopping minutes into the angiogram and going to consult with a colleague.
The 75-year-old retired painter and decorator had just had an angiogram — where dye is injected into the bloodstream during an X-ray
‘When he returned, he said: ‘Mr Fortes, I think you have a wire in your arm,’ says David.
‘I was a bit out of it and wasn’t sure what he was talking about. But within minutes, all hell broke loose.’
Three months earlier David, from Redruth in Cornwall, had had a heart attack, and underwent a procedure to clear a blocked coronary artery to prevent him having another one. Then, one morning, he began experiencing pain in his arm, chest and jaw and had to be re-admitted to hospital for what was thought to be a second heart attack.
No one could confirm whether the wire, which had been used as part of the procedure to clear the blockage, had caused the symptoms — but clearly it should not have been there.
A subsequent investigation by the Royal Cornwall Hospitals Trust found the wire was left behind after David’s treatment to unblock his arteries three months before, in April last year.
The wire was a guide used to push equipment into place — no one had noticed that part of it had snapped off during the procedure and had become lodged in his body.
This was a calamity, classed in the medical world as a ‘never event’ — so called simply because it should never happen, a potentially life-changing blunder that is entirely preventable if medical staff follow the proper procedures.
These events range from surgery on the wrong part of the body to medical equipment being left behind after an operation.
Guidewires specifically are a particularly egregious example. On average, about once a fortnight a guidewire is accidentally left inside an NHS patient, according to research by the University of Cambridge and others published in the Journal of Patient Safety in January this year.
This revealed 236 cases of guidewire retention were recorded between 2004 and 2015, with the numbers increasing as time passed.
‘We found a rising frequency of retained guidewires, with an average of two per month,’ the researchers noted in their report.
The damning numbers…
There were 364 never events (a preventable medical blunder) in England in the 12 months between April 1, 2020, and March 31, 2021. These included:
n 80 cases where patients had foreign objects left inside them after surgery, including 15 surgical swabs, 20 guidewires — used to help guide larger surgical instruments into place — and 23 vaginal swabs.
n 30 cases where the wrong implant or prosthesis was implanted.
n 80 per cent of all healthcare errors are caused by human factors — such as poor team communication — a 2019 NHS report found.
This could be owing to more people undergoing these types of procedures as an alternative to open-heart surgery, but what researchers found most worrying was that, in more than half the cases they looked at, doctors only realised their mistake during follow-up scans months — sometimes years — later, often when patients were admitted for unrelated illnesses.
Some only discovered the blunder when the metal started to poke through their skin. After his initial heart attack, David was rushed by ambulance to the Royal Cornwall Hospital in Truro.
There, doctors carried out an angiogram, which showed a blockage in his main coronary artery — hard deposits (plaques) had ruptured in the blood vessel, restricting blood flow.
Wires embedded in blood vessels
David was told he urgently needed a rotablation procedure to break up the hard deposits.
Performed on thousands of patients every year, this involves inserting a thin wire with a drill-like tip on the end through a tiny incision in the wrist and feeding it up into the chest. The tip spins at high speed and grinds away the plaque.
David’s artery was successfully cleared and a metal tube called a stent was placed inside to prop it open. But at some point during the procedure a 15 in (38 cm) strip of the guide wire broke off and lodged inside the network of blood vessels running from his left elbow up through his shoulder and neck and into his chest.
The widower and father of one was discharged but within days developed what he describes as ‘a painful swelling on the inside of the left elbow and my whole arm ached all the time. The skin started to go yellow, as if I had a bruise forming. I couldn’t straighten my elbow or bend it properly.
No one could confirm whether the wire, which had been used as part of the procedure to clear the blockage, had caused the symptoms — but clearly it should not have been there
‘Because I was already on several daily tablets for my heart, I didn’t want to take painkillers in case it affected how they worked, so I just put up with the agony.’
David managed to get through to a cardiac nurse on the phone who said there might be some tissue damage from the procedure but it would settle down in time.
A couple of weeks later, his GP gave him the same response.
It was only when David suffered his suspected heart attack three months later — with pain in his arm and chest — that the blunder came to light.
Doctors were reluctant to remove the wire because the likelihood was new tissue would have grown around it, making extraction difficult. ‘But I insisted,’ says David. ‘I’m an ex-soldier so I didn’t mince my words. I told them to get it out, whatever it took. And they did.’
This procedure was done under sedation and did not cause any damage. David was fortunate because such errors can be disastrous. Previous research has found up to one in five patients dies after guidewires are left behind in their blood vessels. They can pierce the heart, cause blood vessel blockages that lead to a stroke and result in clots that can become deadly if they migrate round the body and end up on the lung.
The Cambridge researchers said blunders they identified were owing to human error resulting from a failure to follow procedure, pressures of work or inexperience — almost 90 per cent involved junior doctors. Only 36 out of the 236 cases detailed the likely cause — but in most of these 36 cases doctors were blamed for not following proper procedure.
Medical blunders not being tackled
Guidewires are not the only bit of medical kit featuring in never events. Drill bits, scalpel blades, forceps and needles are discovered lurking in patients’ bodies months, or even years, later. In 2016 Good Health reported on the case of Frank Hibbard, 69, who died after surgeons accidentally left a swab inside his abdomen during routine prostate cancer surgery more than a decade earlier.
A coroner’s report concluded the 5 in (13 cm) strip of gauze had triggered the growth of an angiosarcoma, the cancer that eventually killed him.
And evidence suggests the NHS is failing to reduce the number of such blunders. According to the latest figures, there were 297 never events reported in less than a year, between April 1, 2020, and the end of January 2021.
This is lower than the 435 cases recorded between April 2019 and February 2020. Experts agree the fall was owing to a huge slump in elective surgery during the Covid-19 pandemic — but the fact is they aren’t going down.
One patient had vision-correcting laser surgery on an eye that didn’t need it, another had her ovaries mistakenly removed and a third underwent surgery on her rectum — when it should have been her vagina. In about 24 of the cases the wrong skin lesion was removed, while in 20 cases guidewires were left inside blood vessels, and in 34, swabs weren’t removed at the end of surgery.
This isn’t just a problem in the NHS. Figures from the Private Healthcare Information Network, which collates data on private medical care provided by nearly 300 clinics in the UK, show there are about 21 serious safety incidents a year among fee-paying patients. In 2019, in five instances they operated on the wrong part of the body.
‘Never events are perfectly avoidable by using established good practice,’ says Peter Walsh of patient safety charity Action against Medical Accidents. ‘Yet they continue to occur at an alarming rate.’
Are safeguards being followed?
While the chances of falling victim to a surgical never event are slim — the NHS carries out nearly five million surgical procedures each year and mistakes like these occur in about one in 20,000 — what worries experts is that the number of never events does not seem to be declining.
The 2019/2020 total of 435 cases is only slightly lower than the 489 incidents logged in 2011/2012.
This is despite enormous efforts to eradicate them. For example, the National Reporting and Learning System, part of the NHS, recommends inserting and removing a guidewire should be a two-person task; one to carry it out and one to observe that it is done correctly.
This includes verbally agreeing out loud with each other that the wire has been removed and documenting it in the patient’s records. Meanwhile, the World Health Organisation (WHO) recommends all hospitals use a ‘smart’ device called WireSafe, a plastic box that contains the wire, sutures and needles to complete the procedure. Crucially, the box only unlocks — giving access to the sutures and needles — once all of the wire has been removed from the body and fed back into it.
WireSafe has been around since 2016, but a document from NHS Improvement suggests it is not yet in widespread use.
And over the past decade virtually every hospital in the country has adopted the WHO’s surgical safety checklist. The 19-point guide aims to prevent blunders by ensuring theatre staff have carried out routine checks such as ensuring the correct operation site is marked in advance and all surgical equipment, sponges and swabs are accounted for once the procedure is finished.
In another safety initiative, since 2015 it has been mandatory for NHS trusts in England to investigate all serious surgical errors in order to work out ways to stop them happening again. Other steps include appointing Freedom to Speak Up Guardians, as hundreds of hospitals have done. This is a nominated member of staff in an NHS trust whom other employees can approach, without fear of reprisals, if they have concerns about patient safety.
Swab that could have killed new mother
Amy Berry, 28, a former care coordinator for a mental health trust, lives with husband Daniel, 29, a data analyst for a car company, and their daughter Ivy, three (below, with Amy). She says:
What happened to me was a horror show from start to finish.When I was pregnant, my 20-week scan showed that my baby was too big and was moving less. I was monitored for the next 18 weeks, by which time the baby was 10 lb and I had to be induced.
Amy Berry, 28, a former care coordinator for a mental health trust, lives with husband Daniel, 29, a data analyst for a car company, and their daughter Ivy, three (above, with Amy)
On the day they induced me, despite pushing for two hours, the baby wasn’t descending, so they decided to use forceps. They kept pulling but nothing was happening. Then they discovered one of the forcep blades had become lodged on her face. I was really distressed.
A doctor finally managed to pull out the blade but because I was bleeding and there were risks to me and the baby, I had an emergency caesarean. Ivy was born with severe injuries to her face — which have left a permanent scar.
The next day I felt really unwell, with hot and cold sweats, but the nurses said they were discharging me. I remember specifically asking if I was fine to go home and they said I was.
But at home I felt worse every day, with flu-like symptoms and I began shaking with fever. A midwife came to check me but said I didn’t match signs of infection so didn’t need to go into hospital.
I became more ill over the next ten days, with abdominal pain so bad I couldn’t stand up or hold Ivy. Then I started passing fist-sized blood clots: it felt like I was giving birth again.
I called the GP and hospital but they told me it was probably normal after such a traumatic birth, and just to keep taking painkillers. But I felt like I was at death’s door. The next day, 11 days after the birth, I had horrendous tummy pain and then a swab fell out of me. The smell was terrible, which I now know is a sign of a serious internal infection.
Daniel drove me to hospital, where I was diagnosed with sepsis [a life-threatening condition caused by an infection]. A scan showed that part of the swab was still inside my uterus — and because it had been there for almost two weeks, it had caused a pelvic abscess and a hole in my uterus.
They had left the swab inside me during the surgery. It was only luck that it created a hole big enough for some of it to pass through. If the rest had stayed inside me for much longer, it could have killed me. The fact that it fell out saved my life.
I spent the next week in hospital on intravenous antibiotics and morphine — and I continued this treatment at home for two months. I’m still in pain even now, more than three years on, and I’ve had to leave my full-time job. The abscess has potentially caused fertility issues and I now have Asherman’s syndrome, with scar tissue in the walls of the uterus, which reduces its size. Eventually, the hospital apologised. They called it a never event, as it shouldn’t have happened. I got compensation because I’ve been left with potentially lifelong fertility problems and my baby’s face has been permanently scarred. This has been put into a trust fund should she want cosmetic surgery for this when she’s older.
I feel like I just can’t trust anyone in a medical position any more.
Interview: Jinan Harb
Meanwhile, the use of barcode technology is helping operating theatre staff in a small number of NHS trusts to track microchipped surgical instruments such as scissors, clamps and forceps — reducing the chances of them being accidentally left behind.
So why, despite these initiatives, has the number of never events not plummeted?
‘Surgical checklists can make a big difference but only if they are used in the right way,’ says Martin Bromiley, a commercial airline pilot who set up the Clinical Human Factors Group — a charity that campaigns for safer healthcare — following the death in 2005 of his wife Elaine, after mistakes were made during routine nasal surgery she was having for sinusitis.
Anaesthetists had failed to follow emergency procedures for dealing with a blockage in her windpipe and, as a result, Elaine’s brain and heart were starved of oxygen and she died a few hours later. An independent review found it was an entirely preventable error.
Martin says one of the checks on the WHO Safe Surgery list is whether the correct blood has been ordered and delivered should the patient need a transfusion during surgery. He says the team member responsible may simply answer yes because they think they remember it being delivered.
‘But what they should do is check for certain that the blood is not just available, but everybody knows precisely where to find it if they need to access it quickly.
‘Everyone has to be engaged in the process — otherwise it doesn’t work.’
Unfortunately, humans ‘will always make mistakes and in medicine there are a great many opportunities for human error’, says John Pickles, a retired NHS ear, nose and throat consultant who chairs the Clinical Human Factors Group.
‘Never events should not happen — hence the name. But with the best will in the world, it’s unlikely we will ever be able to stop them completely.’
However, he adds: ‘There has been no sign of a downward trend and we don’t know exactly why.
‘Yet we still need to put in place the most effective barriers we can find.’ Mr Pickles and colleagues have spent years trying to get the NHS to follow the aviation industry, where reporting ‘near misses’ and errors is mandatory. The information is not used to punish the pilots involved but to educate others about the potential risks.
However, until 2018, Mr Pickles says, NHS England encouraged local health authorities to fine hospitals for never events.
‘But now they discourage it,’ he says. ‘They realised if people are frightened of being punished they won’t report their errors and safety won’t improve.’
In December, the Royal Cornwall Hospitals Trust — which oversees the Truro hospital where David was treated — said it was addressing its standards of care after an inspection by the Care Quality Commission revealed seven never events between February and October. It says it has tightened up protocols on the use of guidewires.
Chief executive Kate Shields says: ‘We are determined to make our hospitals among the safest in the country.’
Meanwhile, David has instructed lawyers. He says: ‘The hospital has been most apologetic to me about it. But I don’t want this to just go away — I want to be sure that doctors learn from their mistakes.’