“It happened to me”

Two medical students attended my list last week. After the “huddle” and “time out”, I made a little speech about avoiding “never events” in medicine, and reminded them of poor Wayne Jowett who in 2001 received his fatally mal-administered vincristine dose at the same hospital, Queens Medical Centre, where we were operating. The doctors involved came within a whisker of prison. I hoped the lesson would hit home. But I didn’t expect one of them to say “a never event happened to me.”

She had dislocated her right shoulder, but her GP had mis-written “left” on the referral letter. “Left shoulder” was then copied on to the operation list, consent form, operation record and discharge letter. Fortunately, as the nerve block was started, she had been able to say, “No. This one.” and the correct, right shoulder had been operated on. She showed us the scar.

It was a “near miss”, not a “never event”. Four years ago, it had been treated as just “one of those things” – no correction made in the notes, no lessons learned. Only years later did the student discover the error.

I promised I would not mention her name, and I won’t, but she was treated on the NHS in Nottingham. I think things are better now. I hope so.

Jim Thornton