Doctors operate on wrong eye in Worksop hospitals trust blunder

The mistake is one of two so-called ‘never events’ that are being investigated by senior bosses at Doncaster and Bassetlaw Teaching Hospitals which runs both the Doncaster Royal Infirmary and Bassetlaw Hospital during a three month period in 2019.

Hospital bosses say patient involved in the eye surgery mistake had advanced bilateral glaucoma with no sight in the left eye.

After attending the ophthalmology department for a course of laser treatment intended for the right eye, the laser surgery was accidentally performed in the eye he was already blind in. In a separate case which is also being investigated, a patient had a kidney stone and was taken to the operating theatre for a stent to allow the stone to pass.

Due to complications with the X-rays, the stent was inserted into the wrong ureter – one of the two tubes that carries urine from the kidney to the bladder. The patient’s symptoms got better and the stent was later removed as planned.

Sewa Singh, medical director at Doncaster and Bassetlaw Teaching Hospitals, said: “Between April and June 2019, the trust declared two incidents that met the ‘never event’ criteria - patient safety incidents that require in-depth investigation.

“Although in these instances, neither patient suffered long-term harm, we have worked closely with individuals and their families to ensure they were informed of any subsequent learning or changes in process to prevent similar incidents occurring in the future. We continue to work hard to develop a strong learning culture within the trust to minimise all incidents that might compromise patient safety.”

The NHS define ‘never events’ as “patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers”.

The definition adds that each ‘never event’ has the potential to cause serious patient harm or death, but serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a ‘never event’.