Yesterday @TraumaGasDoc posted an incredibly powerful story, Wrongfooted, of a sequence of events that culminated in operating on a patient’s wrong foot. It is a must-read and I pay tribute to him and his medical director for publishing it. Clearly it struck a nerve and over 5,000 people visited the page within 24 hours.
I read it with an increasing sense of deja vu, sadness and even anger. The details aren’t important but essentially we also had a case in October 2012 where we had operated upon the wrong foot with a major contributing factor being that the patient had inadvertently placed a TED stocking on the limb which was due to be operated upon and thus covered up the pre-op surgical marking. The presence of a single stocking is a very powerful distractor from the less obvious absence of a mark and this is a classic example of the complexity of surgery and the huge potential impact of “human factors”. Well-intentioned, highly respected and conscientious staff collectively managed to do the wrong thing. The pre-op marking was done on the ward, the sign-in in the anaesthetic was carried out as was the time out before surgery.
Despite all of these, we managed to line up a series of holes in the “Swiss Cheese” (for the original proposal of the Swiss Cheese model see this book by Prof James Reason or his BMJ article) and the wrong foot was operated on.
I would like to think that we instigated an open, rapid and thorough investigation. Within a week we had a Grand Round about the case with the best attendance of ANY meeting that has occurred in the 12 years I have been at the Trust. Our excellent staff were shocked that this had happened and genuinely wanted to prevent a repeat. The involved surgeon gave an incredibly brave presentation as to how the mistake had happened. Clearly we had to learn lessons and this couldn’t happen again but it was not a case of seeking individuals to blame. At no stage did I contemplate taking formal disciplinary action- no member of staff had wilfully disobeyed protocols. My priority was to prevent a repetition. Singling people out for blame would not have prevented this happening again.
We put a lot of effort into looking at all our processes, paperwork and training. A non-exec director charred a working party looking at all our Safer Surgery procedures . We got in outside experts including ex-BA pilot Trevor Dale of Atrainability and Prof John Clarkson of the Engineering Design Centre at Cambridge. Our staff put in a lot of effort to improve all that we do and I believe that our systems, whilst not perfect, are much safer than they were.
The Chief Executive and I met the patient and were completely transparent about what had happened. Some months later the patient had the operation on the other side, performed by an near identical surgical, anaesthetic and theatre team.

What really saddens and angers me

It was obvious to me that there were lessons in our case that could happen elsewhere and that the NHS needed to learn and disseminate the lessons to prevent it happening elsewhere.
Clearly our case was a “Never Event” and needed to be reported externally. We reported the case to our commissioners, Monitor, the CQC and the National Learning and Reporting Service.
Our local commissioners quite rightly needed to be assured that we did everything internally to prevent a repetition and I have no issue with that. None of the actions from the commissioners included learning beyond the involved provider. Where I start to struggle is what those bodies at a national level have and have not done. Having reported this case , I would expect the NHS to collate samples such as this where there are lessons for all providers. This simply doesn’t happen.
The National Learning and Reporting Service doesn’t seem to have lived up to its billing and indeed in the new NHS it has been disbanded and its activities taken on by NHS England.
NHS England say they will produce a quarterly list of Never Events and indeed you can now “find the Never Events in your Trust” but that is just a list of numbers with no details and does nothing to tell the powerful stories.

What more could/should I have done?

As a group the Medical Directors in the old East of England SHA area continue to meet and the first item on every agenda is to discuss any new Never Events We do this so that we can go back and try to prevent the incidents happening without all needing to make the same mistakes. Unfortunately one thing you can say about Never Events is that they don’t never happen.
I did want to publicise the incident but at that stage it was not the norm and providers seemed only to discuss matters in public if it got out. Very few, if any were bring proactive and open.
I was aware of the power of Twitter and I did discretely hint that we had had issues and sought advice, in a stressful time, from colleagues. I was reluctant to be totally open. I am followed by quite a number of journalists (local and national) and to be honest I feared the reputational risk of talking about a Never Event. There were also concerns about patient (and staff) confidentiality. Unfortunately the overwhelming atmosphere surrounding Never Events is that there is something wrong in the organisation.
In a number of fora I have publicly pointed out that the system seems more interested in what we as an organisation have done and to hold us to account. I have seen precious little effort to disseminate the learning.
I would like to thank @TraumaGasDoc and his medical director for being brave and publishing this powerful story. Unfortunately another patient and another surgical team and hospital have been through what we went through.
Personally, I regret that I didn’t have the courage of my convictions to go talk about this in public.
I do believe that the Duty of Candour will help individual providers go public but I do want to know what commissioners and NHS England will do to disseminate learning in a “blame free” way.