A patient at Doncaster Royal Infirmary had to have her leg amputated following an accidental injection of disinfectant.
The incident is revealed in a report by MPs into the work of the Parliamentary and Health Service Ombudsman.
Bosses at the Doncaster hospital today stressed the incident, which affected a woman named only as Gina, is now used as an example as good practice because it was used to help make sure lessons were learned.
Gina had to have her leg amputated following the accidental injection at DRI, which happened in 2013.
Doncaster and Bassetlaw Hospitals NHS Foundation Trust published a video clip on YouTube entitled ‘The Human Factor: Learning from Gina’s Story’ in September 2014 for staff and organisations across the NHS. It was offered an example of the lessons that can be learnt from local investigations.
Sewa Singh, Medical Director at Doncaster and Bassetlaw Hospitals, said: “We are pleased that the enquiry recognised that Gina’s story is an example of good practice for the NHS.
“Patient safety is at the forefront of everything we do at DBH and if there are any mistakes we make sure that we carry out a thorough investigation, share the findings with patients and their families and ensure Trust wide learning.
“We worked closely with Gina and her husband to make an educational video called ‘Gina’s Story’ that drives home the importance of patient safety and our safety culture and we can’t thank them enough for helping us with this. The inspiring educational video was shared widely both within the organisation, and to other hospitals as we wanted to ensure that no-one else goes through the same experience.”
The incident is mentioned in an MPs’ report which found the NHS ombudsman has been ‘defensive’ and caused ‘pain’ by its reluctance to admit mistakes when investigating patients’ complaints.
It said serious questions had been raised about the Parliamentary and Health Service Ombudsman which has caused ‘considerable anguish’ when it has failed to uncover the truth, it said.
The Public Administration Select Committee has now called for a new independent body to investigate clinical failures before they reach the ombudsman to transform the safety culture of the NHS.
Current systems are complicated, take too long and are preoccupied with blame or avoiding financial liability, the committee warned. There are more than 12,000 avoidable hospital deaths every year, the Department of Health estimates, while more than 10,000 serious incidents are reported to NHS England annually.