Leeds hospital blunders revealed in report

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DOCTORS wrongly removed a woman’s kidney after mistaking it for an ectopic pregnancy, a new report on serious incidents at Leeds hospitals shows.

Two patients also received adrenaline overdoses, there was an outbreak of MRSA among new mums and staff failed to respond when a patient deteriorated, according to the document.

It details 16 serious incidents recorded by Leeds Teaching Hospitals NHS Trust in May and June, with 11 of these pressure ulcers.

The report, by chief medical officer Dr Yvette Oade, says there has been an increase since 2013 in the number of serious incidents.

She said: “Whilst this reflects our reporting and learning culture, this is also attributable to a decision that we took to report all category 3 pressure ulcers as serious incidents from January 2014.”

In another incident, a woman was taken to theatre for removal of a suspected ectopic pregnancy, where a foetus implants outside the womb and cannot survive.

Before the procedure, the surgeon did not review a previous scan which showed one of her kidneys was in her pelvis.

“During the procedure the surgeon identified a structure thought to be the ectopic pregnancy, and removed this,” the report said.

However that was then identified as a pelvic kidney. The woman was not found to have an ectopic pregnancy.

After the error, staff were reminded of the guidelines for treating the condition and there was a meeting about the incident.

In two cases, patients were given too much adrenaline – one who was given ten times the prescribed dose then lost vision in one eye. The sight loss was later found to have occurred at the time of the overdose.

In another incident, a patient on the Critical Care Unit had been prescribed adrenaline at a rate of 5mls per hour following surgery, but it was mistakenly given at 50mls an hour. They needed further surgery but later recovered.

A further incident happened when a patient with diabetes began to deteriorate and was supposed to be monitored every two hours, but this did not happen. The next morning they could not be woken and were treated, but there were delays.

The patient continued to deteriorate due to their underlying illness and died the next morning. A post mortem confirming the cause of death is awaited.

There was also an outbreak of MRSA infection of the skin of mothers who had been discharged from the post-natal ward at LGI. Apologies were given to those affected.

In all cases, the incidents were investigated and moves made to prevent them recurring.

Prof Derek Steele.

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