A DOCTOR at Colchester General Hospital cut the wrong toe tendon during surgery, it has been discovered.

Minutes for a board meeting of the North East Essex Clinical Commissioning Group stated a doctor at the hospital had cut off the wrong toe.

However, now the CCG has amended its minutes to say it was the wrong toe tendon.

The CCG has apologised to the hospital for the incorrect information being released.

The incident was one of a series of "never events" at the Turner Road site, so called because they should never happen.

During 2015/16 there were eight recorded incidents classed as "never events" however some of these errors actually took place in 2014/15 and were upgraded from serious incidents to never events after the investigation was concluded.

A report on the errors, including the case of the wrong toe tendon.

It states: "Four of the confirmed Never Events met the criteria of ‘wrong site surgery’."

This means the wrong part of a patient was operated on.

One patient had the wrong mole removed.

The report does not state whether the removal was due to cancer or cosmetic reasons.

Another patient had an "incorrect hernia repair" and a fourth had an interscalene block given on the wrong side.

An interscalene block involves injecting a large amount of local anaesthetic, normally on one side of the neck for surgery along the side, elbow and forearm.

The report does not state whether the error was picked up before or after surgery began.

Three of the remaining four events involved leaving "foreign objects" in bodies after operations.

On two occasions gauze was left in patients and on another a connector from a removed implant.

The eighth incident involved a misplaced tube in the respiratory rather than gastrointestinal tract.

The report claims root causes included failing to follow safety check and counting procedures, unclear clinical notes, the surgical skin marker rubbing off, poor communication and results being read incorrectly by the surgeon.

The report claimed this is the most never events on record in a year but it is not the most actual events in a year.

A hospital spokesman defended its record stating nine never events actually happened in 2014/15 compared to four last year.

A spokesman for Colchester Hospital University NHS Foundation Trust said: "It is pleasing that the number of Never Events, Serious Incidents and complaints fell in 2015/16 compared with the previous 12-month period.

"It is a sign of the progress the trust made during the year, which is something that both NHS Improvement and the Care Quality Commission acknowledged last month.

"However, in the case of Never Events, one case is one too many and it is essential that we take every possible step to prevent recurrence.

"The Trust is working hard to ensure that it embeds learning from Never Events, Serious Incidents and Complaints throughout the organisation for the benefit of patients in the future."

Serious Incidents at the hospital were cut by about 60 per cent, a marked improvement, however there was a rise in cases of MRSA and Clostridium Difficile.

GAZETTE COMMENT:

NEVER events should never happen.
They are so named for a reason.
These are not incidents where, at the cutting edge of surgery, something goes wrong and somebody dies which can be unavoidable.
These are the wrong bits being cut off patients and items being left inside them meaning more operations.
It is right these incidents are investigated, reviewed, revealed and things are put in place so they never happen again.
But it is tough on our incredible doctors and nurses at Colchester General Hospital who do a remarkable job day in day out when only mistakes are highlighted.
Almost all of us rely on them and many of us, including very recently, have required their help and been delighted with the care and compassion we have received, not to mention the expert medical care.
Nine times out of ten things go well, ninety nine times out a hundred they at least don't go badly.
We all know staff are overstretched and overworked at the hospital and there are too many of us patients for too few staff.
We all know almost nobody in the medical profession would set out to do harm deliberately.
But sometimes things go wrong and keeping mistakes quiet just makes them more likely to happen again.
If it is a mistake after every precaution has been taken, every procedure followed and every lesson learnt it is one thing.
But if steps can be put in place to stop it happening again it is right for the problem to be highlighted and for a solution to be found.