Patient, 61, wakes up from operation to find surgeon has operated on the wrong part of his arm

Patient, 61, wakes up from operation to find surgeon has operated on the WRONG part of his arm by mistake despite drawing an outline on his skin before he started 

A patient regained consciousness to be told ‘I‘ve done the operation wrong‘ by the surgeon who had treated him. 

The surgeon – who had more than 30 years’ experience – operated on the wrong part of Phillip Ivory‘s arm, despite marking his skin beforehand.

The 61-year-old had been experiencing numbness in his fingers and underwent elective ulnar nerve decompression surgery to restore feeling in July last year.

But his surgeon at Castle Hill Hospital in Hull, East Yorkshire, made his incision on the elbow instead of the inner arm where it should have been.

He realised his mistake shortly after while pondering the operation and concluding something ‘did not feel right‘. 

The surgeon asked a nurse to unwrap the bandages on Mr Ivory’s arm and explained his mistake.

Hull and East Yorkshire Hospitals NHS Trust were forced to pay damages to the patient after he brought a medical negligence claim through specialists Hudgell Solicitors.

The trust admitted breach of duty and completed a serious incident report into the matter.

It deemed the mistake a ‘Never Event’ – errors which the NHS accepts are ‘wholly avoidable’ if the proper checks and procedures are followed.

The surgeon operated on the outside of his elbow instead of the inside 

Mr Ivory, an area manager from Bridlington, said he thought the surgeon was joking when he visited him at his bedside shortly after the operation to give him the news.

‘I said to him, “everything alright?” and he never said anything and he asked the nurse to take off the bandage,‘ he said.

‘He the said, “I’ve done the operation wrong”. I was shocked and I thought he was joking with me so I said, “we all make mistakes”. 

‘Then I thought, “oh no, he’s not joking”. He apologised and said he had reported himself to the medical council.‘

The corrective surgery was delayed as Mr Ivory suffered from unrelated health problems, with angina and then a later diagnosis of diabetes.

The procedure was eventually carried out at Castle Hill Hospital seven months later, in February this year, by another surgeon.

Mr Ivory, who is now recovering from the second round of surgery and is waiting to see if he regains the feeling in his fingers, which can take up to a year, said he was shocked that a surgeon ‘of his calibre‘ had made such a simple mistake.

‘He said it was his first mistake in 32 years, and I do think a surgeon of his calibre should not have got it wrong,‘ he said.

‘I couldn’t believe it when he told me, but the inconvenience was the main issue for me, as I was off work for around four weeks each time, so two months in total.

‘I know things do happen and things go wrong, and I’m just glad it was something relatively minor, and nothing major. He was very upset. I would say I’ll be glad to see the back of 2017 and 2018, it hasn’t been great.‘

Mr Ivory said he does not hold any ill feelings towards the surgeon, adding: ‘I think the term “Never Event” is daft, as mistakes can be made.‘

But ‘Never Events’ are being made in their hundreds on hospital wards across the country, including surgical equipment being left inside patients, operations on the wrong limbs, incorrect implants being fitted and the incorrect use of medicines.

Medical negligence specialist Sam Thompson, of Hudgell Solicitors, says they are ‘straightforward mistakes‘ that are ‘often caused by unnecessary pressures that healthcare practitioners are faced with up and down the country‘.

‘Mr Ivory has been very understanding of his situation which is a credit to him,‘ he said. ‘He understands people make mistakes. This case has put Mr Ivory back in the position he would have been in were it not for this event.

‘However, we see many cases where mistakes which are completely avoidable have serious, life-changing circumstances.

‘Mr Ivory had to undergo an avoidable second operation, anaesthetic and period of hospitalisation. He now has a second scar. He missed an additional four weeks of work.

‘Fortunately, Mr Ivory has now had the correct surgery and is hopefully on the mend after a difficult year.‘

A spokeswoman for Hull and East Yorkshire Hospitals NHS Trust said: ‘We apologise to the patient for the error which meant surgery was carried out on the wrong part of his arm. Procedures have been reviewed as a result of this incident.‘

 

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