A Brighton hospital trust patient died after having a toe amputated, according to an official report.
The case was one of six serious incidents in a month to be reported by Brighton and Sussex University Hospitals NHS Trust to local health commissioners.
Three of the incidents reported by BSUH were described as “never events” – events that should never happen.
The six incidents were included in a report considered yesterday by the Brighton and Hove Clinical Commissioning Group (CCG). No identifying details, including at which hospitals the incidents took place, were disclosed.
It said: “A patient was admitted for urgent removal of an ulcerated non-healing toe lesion. The toe was required to be surgically removed which took place. Three days later the patient suffered a cardiac arrest and died.”
A spokesman for BSUH said: “We are limited in what we can say because of patient confidentiality but there is no evidence to suggest that the cardiac arrest was caused by the amputation of the patient’s toe.”
Another serious incident left hundreds of diabetic patients potentially at risk after they were missed off an eye screening programme.
The report said: “The number of patients on the diabetic eye screening programme register differs from the total number of diabetic patients requiring screening produced by GP practices – a difference of 632 people.
“The discrepancy means that there are patients potentially at risk because they have not had their eyes screened.”
The other serious incidents involved four women patients in separate cases. Three women had swabs or gauze left inside them during surgery – the never events – and an 86-year-old woman suffered a broken thigh bone when she fell while on a ward.
A report to the BSUH board on Thursday (26 January) says that there were a further five serious incidents last month although details are not given.
The Pavilions Drug and Alcohol Service reported two serious incidents involving patients from Brighton and Hove in November.
The CCG report said: “Both were reported as apparent / actual / suspected self-inflicted harm.
“A service user died in Worthing Hospital – circumstances unknown at time of notification (and) an unexpected death of a service user was confirmed by the criminal justice section of Pavilions – again circumstances not known at time of writing.”
It would be interesting to know more of the circumstances leading to the 86 year old falling in the ward. Was she accompanied by a member of staff or even two? Or was she on her own?
In the past nurses supported and prevented falls, now they don’t as a matter of policy to protect themselves from suffering on the job injury – pulled muscles, back problems. But they LIE and say “You won’t fall. Just walk. We’re here to help you” And they are NOT. Every patient needs to KNOW they will be allowed to fall and risk injury. Very elderly patients may only know how things USED to be. The bullying of patients needs to be resisted.
Similarly, if you slide down the bed and need help to be sat up better or at all, they now haul out a hoist instead of using their own physical capacity to do it.
Interesting comment from Valerie. Nurses, Healtcare Assistants do NOT just leave patients to fall. Each patient will be assessed on their risk of falling upon admission to a ward. Patients are then supported, based on their condition and need, when they leave their beds or chairs. Of course, on occasion patients may get up without pressing their call bell, and this can be for a variety of reasons. And, sometimes, falls may happen, even with the best will in the world, and when a nurse or HCA is present. Hoists and slide sheets are used to safely move patients’ positions while in bed. This is safe for all parties…the process of ”moving and handling’ patients. This story highlights unacceptable and tragic ‘Never Events’. I doubt that the NHS, or any other health service, will be able to prevent all falls. The emotive language of ‘lying’ and ‘bullying’ can go both ways. So should kindness and compassion.