Deaths are among 26 serious incidents at Leeds hospitals

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Three deaths and three procedures being carried out on the wrong part of a patient’s body were among serious incidents reported at Leeds hospitals in two months.

The latest report into incidents at Leeds Teaching Hospitals NHS Trust shows there were 26 in September and October.

Three involved the deaths of patients – including an elderly man who had fallen out of bed in hospital and hit his head.

The others were a patient who died of blood poisoning after medics struggled to administer antibiotics, causing a delay, and another death following an incident during the insertion of a chest drain in surgery.

The coroner is investigating the circumstances of that, hospitals trust directors were told.

Dr Yvette Oade, chief medical officer, said in a report: “The trust is committed to identifying, reporting and investigating serious incidents, and ensuring that learning is shared across the organisation and actions taken to reduce the risk of recurrence.”

Among the 26 serious incidents, 18 of them were severe pressure ulcers.

The death following a fall out of bed involved a man who had been admitted after falling at home.

“He was identified at risk of falls, and placed in a bed near the nurse’s station. However, despite being checked hourly, he was found on the floor, having climbed out of bed in the early morning, and hit his head,” the report said.

After an investigation, there has been a focus on falls education, as well as a new procedure for patients at risk of falling.

Three so-called ‘never events’ took place where a procedure was carried out on the wrong area of the body.

In one, a patient undergoing surgery to change a stent had the equipment inserted on the wrong side of their body. Since then, an additional check has been added for staff.

Two dermatology patients had the wrong skin lesion removed during a biopsy, one who realised the mistake when she arrived home. The other mistake was discovered during a check in clinic after staff raised concerns. Procedures have been changed to reduce the risk of the problems happening again.

A further incident led to a woman having her uterus removed after suffering a large amount of blood loss following a Caesarean section.

The report said the unit was temporarily closed after the incident to “allow for concentration of resources whilst trying to control the bleeding”. The woman recovered well and her baby was unharmed.

A safety alert was issued to intensive care staff after the oxygen to a patient was found to be disconnected, and there may have been a delay in responding to a warning alarm.