Investigation into Use of Contaminated Surgical Tools Launched

Helen Neville
Author:
Helen Neville
Partner, Medical Negligence
Date:
02/09/2021

An investigation into what steps the NHS takes to prevent contaminated surgical tools being used on patients has launched.

Reusable surgical instruments must be thoroughly cleaned, disinfected and sterilised before they are used on patients. This is to make sure medical devices are safe for use on a patient and for staff to handle without presenting an infection risk.

Decontamination is a combination of processes, including cleaning, disinfection and/or sterilisation, and standards and guidance relating to this has been published over many years.

The requirements for healthcare organisations have also become more stringent as a result of greater knowledge, experience and technological advancements.

But despite this, we do occasionally hear about instances where the decontamination process has not been properly carried out, and a contaminated surgical tool ends up being used on a patient during an operation.

This represents a serious breach of duty and puts the patient at risk of serious illness or diseases. There are multiple blood-borne illnesses, such as Hepatitis B, Hepatitis C, human T cell leukaemia and HIV/Aids, all of which can have huge impact on a person’s life.

Investigation Launched

The Healthcare Safety Investigation Branch (HSIB) has announced it is to carry out an investigation into the decontamination of surgical instruments, which we welcome.

The investigation will focus on what processes are in place to make sure that:

      • The decontamination process is properly managed
      • Incorrectly decontaminated surgical instruments are not used on patients
      • Staff are properly trained to carry out the decontamination of surgical instruments

What Prompted the Investigation?

The HSIB began the investigation following an incident involving a woman who had a fairly routine operation to remove a kidney stone.

During the procedure, clinicians noted some “black” material coming from a small tube within a surgical tool that was being used.

They stopped the operation, recovered the “black” material and sent it to be examined. It was later found to be dried blood.

Thankfully, the patient tested negative for blood-borne viruses and hasn’t developed any symptoms since her operation.

Nowadays, one thinks and assumes that when undergoing an operation or procedure, the equipment is ‘clean’ and presents as no infection risk.

What we are seeing are these events and incidents are still cropping up, where patients are harmed due to contaminated tools being used, or surgery is delayed due to no ‘back up’ instruments being available in the event original instruments are found to be contaminated.

We hope this is an isolated case, but it will be important to establish how this occurred, whether this involves a specific on or off-site decontamination facility, and if it involves multiple patients or hospitals.

I will await the HSIB investigation but in the meantime, hospitals must be alert to checking there are systems in place to ensure equipment is sterilised, checking the training requirements for staff who undertake decontamination of surgical instruments and assess the level of communication that exists between the decontamination facility and theatre staff.

If you have any concerns about the treatment you received during an operation and whether the correct processes were carried out, get in touch with our Medical Negligence Solicitors.

Our friendly team of experts offer a free claims assessment, and we’ll be happy to discuss your situation with you, with no obligation to you.

For free legal advice call our Medical Negligence Solicitors

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