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Dept of Health

Answer

Mr. Geoffrey Robinson: To ask the Secretary of State for Health what steps were taken by the Walsgrave NHS Trust management to investigate the surgical mistake that resulted in an anvil being left in a patient's rectum; and when the patient was informed of the mistake. [159611] Yvette Cooper: [holding answer sent 03 May 2001]: Our White Paper "A First Class Service" sets out a requirement for all organisations within the National Health Service to set up and implement a clinical governance framework, which identifies procedures to be followed when reporting and investigating clinical and untoward incidents. Such procedures should enable incidents to be investigated thoroughly in a culture of openness and reflection to ensure lessons are learnt and clinical practice improved. In this particular case, a clinical incident report was completed on 10 December 2000. The head of nursing for theatres was asked to undertake a thorough investigation to review and revise the necessary trust theatre procedures. As a result of the investigation, the importance of following theatre-checking procedures was reinforced to theatre managers and staff, and all theatre procedures were reviewed and amended accordingly to reflect lessons learned through this incident. The clinical director for surgery has ensured that junior doctors involved in colorectal surgery have a clear understanding of the operating mechanisms of the stapling gun. In addition, the Trust medical director also wrote to all consultant surgeons who carry out colorectal surgery reminding them of the need to be present throughout this kind of surgery. The consultant surgeon responsible for his care informed the patient on 18 January 2001 that the anvil had been left in their rectum following the operation of 4 December 2000. The patient's wife and another family member together with the specialist stoma nurse were present during this discussion.

Secondary information

Type

Written question

Reference

368 c362-3W; 159611

Session

2000-01

Subjects

Hospitals Medical treatments Patients Negligence Surgery University Hospitals Coventry and Warwickshire NHS Trust Walsgrave Hospitals NHS Trust

Link

View this Written question on www.publications.parliament.uk