Saturday, September 02, 2006


Their "count-out" was so casual that nobody even bothered to fill out the form. But again no penalty whatever for killing a patient

A man aged 79 slowly starved to death after hospital staff accidentally left an 18in cotton pad in his intestine at the end of an operation. In the ten following months, the forgotten swab - used to soak up blood and other fluids - blocked the natural absorption of nutrients, an inquest was told.

The swab should have been ticked off a list of items to be removed from Robert Twycross at the end of the procedure at Royal Hampshire County Hospital, Winchester. But Chaudhary Usmani, the surgical registrar, admitted that the check sheet that was normally used had not been filled in by the nurses, although he claimed the check had been carried out. "The check was done, it had not been ticked but it was done," he said. "I would never, ever close an abdomen without checking. Never ever. "Accidents can happen but swabs have to be checked. I have been in surgery for long enough, I've never done an operation when the swab check was not done."

Christian Wakefield, a consultant general surgeon who performed the operation jointly, said that the hundreds of swabs, along with other surgical instrument, were counted immediately before the operation, when they were used, and again when removed from the patient. Yet despite three checks by the two surgeons and two nurses present, the swab had been left inside the pensioner's digestive system.

Human error was to blame for the mistake, Mr Wakefield acknowledged. "The most likely cause for the oversight was that a nurse had miscounted the swabs when they were taken out after the operation," he said. "This could have happened by two swabs getting stuck together, because they can shrink in size when full of blood. "It was a case of miscounting and human error is the likely explanation."

The inquest, at Winchester, was told that Mr Twycross, of Acre Court, Hampshire, was readmitted to the hospital suffering from abdominal pains, diarrhoea, malnutrition and dehydration on February 28 last year, ten months after the surgery in April 2004. He underwent further emergency surgery, performed again by Mr Wakefield, which revealed the infected swab. Numerous check-ups after the first operation had failed to detect the swab, despite a visible lump under Mr Twycross's skin.

The pensioner was subsequently moved to a nursing home and made frequent trips to the hospital until his death on October 4 last year. The pathologist's report described the death as "unnatural" and concluded that the error had contributed to, but was not the sole cause of, his death.

In his verdict, given on Wednesday, Grahame Short, the Central Hampshire Coroner, said: "I've found that the retention of a swab was accidental. It was not the sole cause of death. Robert Twycross died as a result of malnutrition due to a retained surgical pack. He also suffered from ischaemic heart disease and jejunal diverticulosis."

Mr Wakefield agreed, conceding: "I believe he could have healed, although it would have been a very long process and if the swab had been found earlier it would have improved his recovery." An internal investigation was carried out at the hospital but no disciplinary action was taken. The hospital has implemented an extra count of swabs and instruments after surgery to ensure that nothing is left behind.


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