A teenage from Wales discovered he is involved in a terrifying hospital scandal when a mysterious man knocked on his door.
15 year-old Ieuan received some terrifying news when a mysterious man showed up at his door (Image: Conor Gogarty)
A young teenager from Wales discovered just days after a procedure that he could be at risk from serious illness after a mistake made by the hospital.
Three weeks after Ieuan Williams, 15, underwent a brace-fitting at at Newport’s Royal Gwent hospital, his family recived a mysterious knock at their door from a man wearing scrubs and a surgical mask.
The unknown visitor then handed them a letter from the director of the Aneurin Bevan university health board that read: “It is important that we speak with you, so we kindly ask that you contact us as soon as you are able.”
Initially, Lee and Karen Williams of Cwmbran, South East Wales, were unsure what the letter was referring too but soon wondered if it could have anything to do with the seemingly simple procedure their son had had on his teeth, reports Wales Online.
After making a few phone calls, the horrified parents discovered that Ieuan is among 21 patients to have been affected by a catastrophic failure by the hospital which lead to them using unsterilised medical instruments on patients on February 25 and 26.
This oversight by the hospital now leaves Ieuan and the affected patients at risk of contracting blood born diseases such as HIV, Hepatitis B and Hepatitis C. Although the shocked family have been reassured the risk is “very low”, Ieuan will have to undergo four rounds of testing across a six month period before he can receive the all clear.
The Royal Gwent hospital used unsterilised medical instruments on 21 patients (Image: WalesOnline/Rob Browne)
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These failings by the Royal Gwent hospital were initially uncovered by WalesOnline when a whistleblower came forward with information about the incidents.
Mum Karen said: “If it wasn’t for the whistleblower, would we have ever known? They need to be more transparent with us. We need to know exactly how these errors happened.”
According to Karen, the phone call they took with the hospital on Wednesday when they discovered the news affected them all deeply. “I couldn’t process it,” she said. “I was thinking, ‘How do I tell Ieuan this?’ This is not something a 15-year-old should have to worry about.”
The following day, more information about the incident was revealed to the family and they learned that the unsterilised instrument used in Ieuan’s 20-minute orthodontic procedure had been a pair of pliers for cutting off the excess wire from his braces and a mirror.
According to the health board, the instruments in question, and those used in other procedures on other patients, had been disinfected but had been failed to placed in the autoclave – a machine that sterilises medical tools using heat and steam.
A tape placed on medical instruments is designed to change colour when exposed to this heat and steam of the autoclave, in turn indicating to staff which instruments are clean and safe to use – and which are not.
It is the staff’s responsibility to ensure the tools they use have the correct colour tape but, in this case, this was not done. The only explanation given by the health board so far has been “human error”.
Dr Seema Srivastava medical director of the Aneurin Bevan university health board said: “We are very sorry this has occurred and for the distress caused to those affected and their families. We fully recognise the impact this has had on those people.”The instruments were fully disinfected, and that in itself reduces lots of microorganisms. They are then meant to be put into a final stage machine called an autoclave, and that helps do the sterilisation process to ensure the instruments are free of specific viruses.”The hospital admitted the autoclave was not used on tools used for two days of surgery – and he mistake noticed a day later.Dr Srivastava admitted there was a risk of patients contracting viruses, saying: “There is a potential but extremely low risk.”Although we have strong processes in place, human error can occur, and I know that has happened in this situation.”We immediately took steps to remove those instruments from circulation, and stood up a specialist team to investigate this matter.”A number of medical instruments are reusable in healthcare treatment, and every hospital has a sterilisation and decontamination unit. We’re talking about a limited number of instruments affected by this issue.”We have been working very closely with an expert virologist, and that is why we are confident in saying the risk is extremely low.”Patients have been contacted and supported by our team of nurses. They have had answers to any questions they have, and we are arranging for any tests they might need.”We have started an active investigation into what happened. It will take time to ensure we have a thorough review.”I visited the sterilisation and decontamination unit earlier today, and I can see how deeply committed the staff are in ensuring patient safety, and the number of checks that were already in place. But we have now added further to ensure this doesn’t happen again.”We are conducting a full review. There’s nothing else I want to say about that at this stage.”It’s important to come back to how very sorry I am that the incident occurred and that distress has been caused to those affected. And it’s really important to know that if patients have not been contacted, they will not have been impacted by this issue.”
Ieuan, who will return to the hospital for his second of four tests in two months, said: “I was quite scared at first. I’m going to have to go back and forth to the hospital for six months. They keep saying how low the risk is but I want to know for sure.
The board also addressed why the it waited until three weeks after the incident to inform patients, saying: “We really needed to be sure we had an accurate list of patients and that we were only contacting those impacted. We needed to be clear about what steps were taken to ensure their health needs are responded to.”
Asked if disciplinary action was being taken, medical director Dr Seema Srivastava replied: “We are conducting a full review. There’s nothing else I want to say about that at this stage.”
Lisa Dymock, Tory councillor for Portskewett, said: “It’s hard to understand how so many failings could happen at various levels without being properly addressed until they felt the pressure from the press… Answers [are] needed urgently.”
And Laura Anne Jones, Reform MS for South Wales East, said: “It’s scandalous that it’s taken three weeks for my constituents to be informed.”
The Welsh Government said: “We have been assured the health board is taking all precautionary measures to prevent incidents like this from happening again.”