Cases of wrong-site surgery in England have risen from 69 in 2020 to 101 last year, with 7% involving serious harm to patients.
Between 2020 and last year, 661 cases of surgery performed on the wrong patient or body part were reported in English hospitals, according to new data from Medical Negligence Assist.
The phenomenon, known as wrong-site surgery, is a medical error where an invasive procedure is performed on the wrong patient, the wrong body part or the wrong site on the body – such as operating on the left limb instead of the right. Many of these incidents are classified as “never events” by the NHS, meaning they are considered entirely preventable.
Obtained via Freedom of Information requests, 117 NHS Trusts were contacted. Of the 72 that responded, 661 cases were reported in total over the five-year period. While 69 incidents were recorded in 2020, that had jumped to 101 last year, marking a 46% increase in cases during that time.
The true figure is likely to be higher – some of the responding Trusts declined to specify exact figures due to smaller numbers, in order to protect patient confidentiality.
“The increase in the numbers demonstrates that these Never Events are becoming common, and is something that everyone should be concerned about as the consequences can range from the catastrophic to unnecessary scarring to avoidable pain and discomfort,” said Gareth Lloyd, head of medical negligence at JF Law.
“These never events can be avoided, and more needs to be done to tackle the issue, especially in those Trusts that have seen the highest numbers,” he added.
“For patients, wrong-site surgery can be devastating, particularly when it leads to avoidable harm or additional procedures,” said Matilda Blundell, trainee solicitor at Tomlin & Partners.
“The fact that these incidents continue to occur, despite being classified as ‘never events’, suggests that more needs to be done to ensure safety systems are consistently applied. Learning from these cases is essential to prevent similar mistakes in the future.”
Human error
Of those 647 cases, 46 (7%) are reported to have involved the patient suffering serious harm, with incidents ranging from the wrong anatomy being removed to the excision of a pair of organs when only one was slated for removal.
Meanwhile, 236 involved moderate harm to the patient, such as the wrong tooth being extracted, incorrect scars being removed, or Botox being injected into the neck instead of the mouth.
A total of 292 cases involved low harm, such as biopsies or anaesthesia being erroneously applied, while only 174 – just 26.89% of cases – resulted in no harm to the patient.
Inevitably, some Trusts reported higher numbers of incidents than others. The Newcastle-upon-Tyne Hospitals NHS Foundation Trust recorded 44 cases of wrong-site surgery over the past five years, with 10 of those having taken place in the first quarter of last year.
Manchester University NHS Foundation Trust also reported a notable figure with 20 cases, though it should be mentioned that neither of these two trusts reported cases involving serious harm to patients.
More seriously, University Hospitals of Morecambe Bay NHS Foundation Trust reported 23 cases, with two of those involving serious harm to patients, while there were 20 instances recorded by North West Anglia NHS Foundation Trust, 13 of which involved serious harm.
There are many reasons why wrong-site surgeries can take place. A common theme among causes listed by the responding NHS Trusts was inevitably human error, as well as procedures not being followed, and non-adherence to safety checklists.
Issues with communication and organisation were also commonly cited, as well as environmental factors such as lighting and temperature. Some reports simply listed issues with documentation, suggesting handovers had not been clear enough or that information had been recorded incorrectly.
In other cases, the Trusts listed causes such as procedures being inadequate to deal with the circumstances, or issues with the information supplied on consent forms, often due to language barriers. Some just admitted that the wrong part of the anatomy had been identified.
Beyond that, investigations made reference to inadequate or faulty equipment, or even the inaccessibility of necessary equipment.