REVEALED: Deaths following serious errors at Sheffield hospitals

Two patients died following errors at a Sheffield hospital within the space of a fortnight, it has emerged.

Friday, 6th January 2017, 9:01 am
Updated Monday, 9th January 2017, 12:02 pm
Northern General Hospital in Sheffield

One person died after a delay in treatment at Northern General Hospital's A&E department on March 8 last year, and the other following a delayed diagnosis at the same hospital on March 18.

Those fatalities were among five recorded by Sheffield Teaching Hospitals during 2016 which happened after suspected safety errors at hospitals managed by the NHS trust.

Royal Hallamshire Hospital in Sheffield

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The other deaths followed a fall at Royal Hallamshire Hospital, incorrect cancer treatment regimen at Weston Park Hospital and issues with the management of a 'deteriorating patient' at Northern General Hospital.

They were revealed in a list obtained under the Freedom of Information Act of the 32 'serious untoward incidents' (SUI) recorded by the NHS trust during 2016, up to November 23.

SUIs are events where the potential for harm is so great they require immediate investigation to reduce the chances of a repeat.

Some of those incidents occurred during 2015 but were only recorded last year. The total number of SUIs so far reported to have occurred during 2016 is 29, which is lower than in either of the previous two years.

Weston Park Hospital in Sheffield

That figure is a tiny proportion - one in nearly 69,000 - of the two million patients seen at the hospitals during the year.

While some of these incidents resulted in death or serious injury, others caused no harm to the patients concerned.

It is also important to note that patients who died may not have survived even without the potential safety breaches having occurred.

Dr David Throssell, medical director at Sheffield Teaching Hospitals NHS Foundation Trust, said: "Our priority is always to provide safe, high quality care and of the 2 million patients we cared for last year, there were 29 reports of a serious untoward incident.

Royal Hallamshire Hospital in Sheffield

"We take every one of these incidents extremely seriously and always undertake a full investigation into the causes.

"We are very sorry that any of these events happened and especially where the incident tragically resulted in harm to the patient.

"Often the incident is not the result of a deliberate failing, more often than not it is a case of genuine unintentional human error but in all the instances reported, a range of actions have been implemented with many additional checks and procedures put in place to help limit the chance of these errors happening again."

The list of SUIs investigated by the trust last year included one 'never event' - a blunder so serious and preventable it should never be allowed to happen - in this case anaesthetic being applied to the wrong part of a patient's body at Northern General Hospital. The mistake was identified before surgery began, and the patient was unharmed.

Weston Park Hospital in Sheffield

Other safety alarms reported at the city's hospitals last year included a failure to diagnose liver cancer, a breech birth which resulted in a baby requiring resuscitation, and a tourniquet being left on the arm of a patient who subsequently developed deep vein thrombosis (DVT).

Extra training sessions, increased supervision and new guidelines are among the changes implemented following investigations into SUIs at the hospitals, to prevent such errors reoccurring.

During 2015, the trust recorded 31 SUIs across its hospitals, including two never events, and in 2014 there were 35 SUIs and three never events.

Ten of the most serious errors recorded during 2016

Hospital - date - incident - outcome

* Northern General Hospital, January 13 - anaesthetic applied in wrong location - no harm* Royal Hallamshire Hospital, January 14 - failure to diagnose liver cancer - delayed treatment* Royal Hallamshire Hospital, January 20 - wrong medications administered - extended stay in hospital* Northern General Hospital, March 8 - delayed treatment in A&E - patient died* Northern General Hospital, March 18 - delayed diagnosis - patient died* Royal Hallamshire Hospital, May 29 - fall resulting in head injury - patient died* Weston Park Hospital, June 13 - incorrect cancer treatment regimen - coroner's inquest pending* Jessop Wing maternity unit, July 17 - breech birth - baby required resuscitation on delivery* Northern General Hospital, September 29 - tourniquet left on patient's arm - patient developed deep vein thrombosis* Northern General Hospital, October 25 - management of a deteriorating patient - patient died