Hospital trust chairman orders review into virtual clinics after patient given wrong treatment
Patient had wrong eye injected after scan mix up
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By Sarah Ward
A review into the new risks that virtual clinics could expose patients to, has been called for at Kettering General Hospital, after a patient had an unnecessary procedure after a scan mix up.
Chair of the hospital trust Alan Burns has made the call after the board discussed a ‘never event’ that happened earlier this year in which patient Paul Toop, who suffers from a degenerative eye condition was injected in the wrong eye after medical staff uploaded another patient’s scan to his file.
At a virtual clinic Mr Toop pointed out during a phone conversation to a surgeon that the injections were usually in his right eye but his concerns were not checked and he was injected in the wrong eye on two occasions in April and May of this year.
It was only when the scans were looked at in June that it was discovered that they did not match earlier scans from January and that Mr Toop’s eye had been injected unnecessarily.
Like a number of health providers the hospital has since Spring 2020 moved a number of appointments online or via phone, due to the Covid pandemic to try and stop the spread of the virus.
Chair Alan Burns said at the board meeting: “Patients are genuinely concerned about the increased risk that occurs in non face-to-face meetings. I am more concerned about the risks that flow from the patient not being in the room.
“I think we just need to go out of our way to look at the new systems that have been implemented as a result of Covid, mostly for good reasons, and think about any of the risks we generate that we don’t know about.
“I can’t believe the one that has just happened in ophthalmology is the only one.”
In a recorded interview shown to the board Mr Toop, spoke of the pain during the procedure, which he likened to having a knitting needle poked in his eye. He praised the processes at the hospital during his care but was incredulous he could have been given a treatment intended for someone else.
“I found that I compared it to a house. You can have everything right at the top of the house but if the very foundations are wrong the whole thing falls down. That was my amazement at it.
“I just could not see how it’s so precise at one end and then something like looking at someone else’s scans with an unusual surname.
“The vision in my left has improved as a result, but that isn’t really the point. They shouldn’t have injected the left eye and they did.
“You read in the paper where they do something on the wrong limb and you just think ‘how can that happen?’ I remember feeling when I finished the conversation (with the ophthalmologist who informed him of the error) - well that has happened to me there now.”
Never events are classified by the NHS as situations that should not have happened.
The University Hospitals of Northamptonshire group (made up of the county’s two acute hospitals in Kettering and Northampton) had had five never events in the past year and last month held a learning session to discuss them and hear from the medical teams involved.
In the aftermath of Mr Toop’s situation the Kettering hospital has now introduced a system to stop scans being uploaded to the wrong patient’s file and has also brought in measures so that scans can be checked in the same room where the injection is taking place.
The hospital has also said it has introduced a new philosophy across the hospital which welcomes challenges, whether from a patient or staff member.
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