The Royal Stoke Hospital makes the same surgical mistake three times

A hospital has carried out three wrong-site operations in as many months and bosses are yet to find out why this continues to happen.

The three “never events” at Royal Stoke University Hospital involved the removal of false lesions and scars from patients during surgery.

After the second incident in February, the hospital assessed what lessons could be learned to prevent a recurrence, but in March a third operation was performed on the wrong site.

A thematic review of the three errors is currently underway, which will provide recommendations on how processes could be improved to reduce the risk of future incidents.

A recent wrong-site surgery report states that a patient attended an appointment in February after being referred for a lesion on his scalp.

But during the appointment, the doctor reviewed an old referral from 2021 that related to a lesion on the patient’s neck that was being treated at the time.

This led to the patient having to undergo a punch biopsy on his neck in March. The error came to light the next day when his daughter raised concerns that the wrong lesion had been operated on.

The first reported incident occurred in January when a patient had a scar removed in the dermatology department.

It subsequently emerged that the surgeon had operated on an old scar that the patient had removed in 2017.

Another wrong site surgery with a wrong lesion was performed in January but was not reported until after the patient was discharged from the hospital the following month.

Head nurse Anne-Marie Riley told a meeting of the University Hospital of North Midlands board of trustees that further work would be carried out to resolve the problem.

She said: “After the second incident, at that point they believed they had taken every measure to prevent something like this from happening again, but that obviously wasn’t the case.”

Every option, internal and external, will be reconsidered, she said.

“The team has done really intensive work looking for very specific checkpoints to prevent something like this from happening again, but clearly something failed and we need to understand why.”