Delays led to serious incidents at Leeds hospitals

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Delays at Leeds hospitals contributed to two serious incidents, a new report shows.

In one case, a patient with a complications following a hip replacement did not have urgent treatment and later died.

In another case, cancer surgery which should have been scheduled within six weeks did not take place for 17 weeks.

Both are documented in the latest report on serious incidents recorded by Leeds Teaching Hospitals NHS Trust, covering July and August.

There were 11 serious incidents during that period, seven of which were serious pressure ulcers.

Dr Yvette Oade, chief medical officer at the trust, told a meeting of hospital directors: “We are continuing to work with colleagues to understand the root causes and to reduce these.”

Two of the other incidents involved delays.

One occurred when a patient developed an infection at the site of a hip replacement.

He was transferred from LGI to Chapel Allerton hospital late at night but his condition deteriorated overnight, which meant the next morning he needed an immediate transfer back to LGI for urgent treatment.

The report said: “There were apparent delays in undertaking a further operation and wash out of the infected joint.

“The patient developed an overwhelming infection before further surgery could be undertaken, and despite full intensive care therapy they failed to respond and subsequently died. The patient’s death has been reported to the Coroner.”

A review has been carried out, with input from all consultants involved in the patient’s care, to look at potential problems and how to address them.

In another case, a patient was seen in December 2013 and added to a waiting list for cancer surgery.

The procedure was supposed to take place within six weeks, but it was 17 before it was arranged.

“Unfortunately, during this time the cancer had progressed and following further diagnostic tests the patient underwent surgery in May 2014. The patient is now receiving palliative radiotherapy treatment,” the report said.

An investigation into the incident will look at communications and the administration process for patients on the waiting list.

The other incidents included a baby who suffered a tear in a vein during a procedure and a patient whose feeding tube was mistakenly placed into their abdomen.

Dr Oade added: “There were a range of different kinds of incidents. They are clearly very significant for the patients concerned.

“We continue to improve the ways that we share the serious incident learning.”

Prof Derek Steele.

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