A LIST of major surgical blunders has revealed a needle, swabs and a sponge among the items left inside patients following operations at Oxford hospitals.

Nine “never events” – serious and largely preventable patient safety incidents – have been recorded by the Oxford University Hospitals Trust (OUHT) since 2008.

The term refers to incidents where the wrong body part has been operated on, or an instrument has been left inside a patient after an operation.

In 2012/13 a swab was left inside a patient following a kidney transplant and a swab was left inside the abdomen of a patient after liver surgery.

Other incidents include part of a “grasper device” left inside a woman following a gynaecological procedure, and a swab lost following delivery of a baby.

Last year there were two “never events”, the same total as in 2011/12.

In 2008/09 four were recorded, including a sponge left inside a chest cavity; a stitching needle lost following a kidney operation; and a swab lost following a gynaecological procedure. The incidents all concern operations at the John Radcliffe and Churchill hospitals, but the trust was unable to provide further information.

Oxfordshire-based lobby group Patient Voice said it was “shocked” by the findings.

Chairwoman Jacquie Pearce-Gervis, pictured, said: “Even two is two too many, never mind nine over the years.

“They will talk about the number of operations they perform but in truth it could be any of us.

“They must explain what precautions are being taken to ensure that next year none of these awful events happens again.”

The trust said there were no examples of items other than those broadly classified as surgical instruments left inside patients following surgery.

Peter Walsh from Action against Medical Accidents said: “The first priority for the trust is to ensure there is a full and thorough investigation into the circumstances of the most recent events and they get to the bottom of what has happened.

“By definition these events are perfectly avoidable with good practice.”

Medical director for the OUHT Prof Edward Baker said: “Any error at the time of surgery or invasive procedure is regrettable.

“However, modern surgery is very safe and adverse events, including very rare retained foreign objects, need to be set in the wider context of the volume of operations and procedures undertaken in a trust of this size.OUHT typically performs 50,000 operations per year.

“Following the most recent event in 2012, the trust implemented a number of actions including improved monitoring, additional training and changes in theatre management.”

Earlier this year NHS England said national figures of “never events” were too high and it had introduced new measures to ensure patient safety.

WHAT WENT WRONG IN SURGERY

Incidents:

  • 2012/13 - 2

Retained swab within abdomen following kidney transplant..
Retained swab within abdomen following liver surgery.

  • 2011/12 - 2

Retained swab within abdomen following bowel surgery.
Retained swab within vagina following instrumental delivery of baby.

  • 2010/11 - 1

Portion of a grasper device (keyhole surgery) retained following a gynaecological procedure.

  • 2009/10 - 0
  • 2008/09 - 4

A small sponge retained within chest cavity following cardiothoracic surgery.
Needle (for stitch) retained following kidney operation.
Retained swab within vagina following instrumental delivery of baby.
Retained swab within vagina following gynaecological surgery.