Never Event Victim Speaks of Shock Over 15-inch Wire Left in Arm

4 February 2021

A man who was suffered ‘horrific’ pain after a 15-inch wire was left in his arm following surgery for a heart condition earlier this year has spoken of his upset over his follow up care, and after learning that had experienced what the NHS called a Never Event.

David Fortes, 75, was rushed to the Royal Cornwall Hospital, part of the Royal Cornwall Hospitals NHS Trust, on April 30th, 2020, having suffered a second cardiac episode in just four months.

The following day he was taken into surgery for what is known as a Rotablation, during which incisions are made to both wrists, and a wire with a drill on the end is used to clear the blockage in the artery before a stent is inserted.

Despite some pain, discomfort and swelling in his arms following the operation, he was under the impression that it had gone well, and as he was unable to have visitors due to the pandemic, he was pleased to be informed by his medical team that he was able to go home the next morning.

However, in the weeks that followed Mr Fortes’ left arm did not improve, and after some difficulty seeking medical advice he was told he may have suffered some tissue damage. A further visit to his GP for an appointment which took place through a car window resulted in the same diagnosis, and he was advised to keep an eye on it, and to get back in touch if the symptoms continued.

On July 20th, almost three months after his original surgery, he suffered a third cardiac event, and it was then that the cardiologist performing the procedure found the wire which had been left in his arm.

The retired painter and decorator has now instructed leading Medical Negligence Lawyers to investigate the care he received, and whether more could have been done to prevent his injuries, with his Lawyer Jodie Cook saying that both the Never Event, and the subsequent care he received, were ‘deeply concerning’.

According to the latest figures published by the NHS, 145 serious incidents occurred between April and September 2020, including cases where medical equipment was left in the body after a procedure, transfusions of incompatible blood components of organs, and surgery that was administered to the wrong site.

Never Events are described within the report as ‘serious, largely preventable patient safety incidents’ that should not occur if healthcare providers have ‘implemented existing national guidance or safety recommendations’.

Speaking of his ordeal, Mr Fortes said that while he was ‘deeply aware and sympathetic’ to the pressure that the NHS has been under throughout the pandemic, he was also ‘deeply distressed’ by the lack of follow up care and compassion he had received.

He said, “When I underwent the surgery, I was very aware of the pressure that the NHS was under, and I was extremely grateful to my medical team for acting so quickly to treat my heart condition.

“However, when things started to go wrong during my recovery, and the pain I was experiencing was getting quite horrific, I found it very difficult to find someone who would take my concerns seriously, and despite multiple attempts to see someone I was simply fobbed off.

“It wasn’t until I was back in hospital again that a scan revealed the wire. By then, my arm was totally immobile. It was stiff, sore, swollen and I couldn’t use it for even the most basic of things. I dread to think what would have happened if it had been left in for any longer.

“It is also deeply distressing that even though I suffered what it known as a ‘Never Event’, I have had no follow-up appointments with regards to the removal of the wire at either hospital or my GP.

“I just feel like no one is really taking it seriously, and it’s deeply worrying to think that there are five other people at the same trust, and over 140 people across the country, who are suffering in the same way as I have.”

Jodie Cook, a specialist Medical Negligence Lawyer who is representing Mr Fortes said, “These figures, and Mr Fortes personal experiences of both the occurrence of a Never Event, and the subsequent care he received, are deeply concerning.

“As outlined in the report from the NHS, a Never Event is serious, largely preventable, and indicative of a wider systemic problem.

“We very much hope to engage with Royal Cornwall Hospitals NHS Trust to better understand the care that Mr Fortes received – both during the surgery itself, and subsequently – and whether more could have been done to prevent his injuries.

“Equally, we hope that lessons are learnt in each and every one of the Never Event cases which were identified during the lockdown period, and that meaningful action is taken to ensure that others don’t suffer as a result of such preventable incidents moving forward.”

While the report also suggests that the actual number of Never Events was lower during the lockdown period, during which the NHS was responding to the Covid-19 pandemic – with 435 cases reported between April 1st 2019, and 29th February 2020 - it also implies that the reduction in instances was as a result of ‘major shifts’ in service provision away from planned and elective surgery.

Most of the Trusts named reported just one or two Never Events, yet others reported far higher numbers including Barts Health NHS Trust which reported five incidents, Liverpool University Hospitals NHS Trust which reported four, and Royal Cornwall Hospitals NHS Trust which reported six.

Jodie Cook of Simpson Millar, which represents a number of patients affected by Never Events said, “While we welcome the fact that the reporting of incidents has been maintained during the Covid crisis, and that there has been a drop in the number of cases of Never Events, the reality remains that 145 very serious failings in care were recorded.

“The impact of such negligence can be far reaching, and in many cases, patients suffer significant injury and face further medical procedures in order to rectify what has gone wrong.

“As normal planned procedures start to get back underway, many patients will be looking to the NHS for reassurance that lessons have been learnt from the cases that have been identified, and that numbers will not start to creep back up.”

The full report can be found here.

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