Hospital trust faces fine after surgery patient is burned by warming blanket

http://www.theguardian.com/uk-news/2014/dec/12/hospital-fine-burn-warming-blanket-surgery-maidstone

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A hospital trust is set to be fined hundreds of thousands of pounds after patient suffered serious burns during surgery, a court has heard.

Mike Wilcock, a health and safety inspector, needed a skin graft on burns to his right buttock and hip after an operation to remove a cyst on his kidney at Maidstone hospital in Kent.

His injuries were caused by a warming blanket – known as a “hot dog” – used on patients during surgery which staff at the hospital had not been properly trained how to use, Inner London crown court heard.

Maidstone and Tunbridge Wells NHS trust is now facing a fine after it admitted failing in its duty under the Health and Safety Act 1974 to ensure the safety of a patient.

At a sentencing hearing on Friday, prosecutor William Davis told the court Wilcock had gone through a “stressful and painful experience” since the procedure in September 2012.

The temperature of the warming equipment, which can rise to 50C in less than an hour, had soared during the operation because a cold saline bag was touching a sensor, the court heard. “It caused the mattress to become extremely hot,” Davis said.

No alarm was raised during the operation and his injuries were only discovered when Wilcock, 58, woke to discover a large burn on his right hip and buttock, the court heard. He was referred to a burns unit and has needed repeated hospital treatment for the injury; he has also developed heart problems, the hearing was told. “Mr Wilcock has suffered serious and ongoing effects as a result of his injury,” Davis said.

The court heard that he hospital trust had committed eight breaches of duty over 17 months after first acquiring the equipment in April 2011. They included failing to provide adequate training to staff on how to use the equipment and not properly investigating two previous incidents, including one patient who received minor burns caused by the machine.

Wilcock, who works for the Health and Safety Executive, is now pursuing a civil claim.

The trust’s medical director, Dr Paul Sigston, offered a direct apology to the patient and his wife, Eileen, when he appeared in the witness box during Friday’s hearing.

He said: “I’d like to express to Mr and Mrs Wilcock that I’m deeply sorry this event occurred. I’m aware of the harm and stress impacted on their lives.”

After the hearing, Wilcock, from Tunbridge Wells, said his injuries had “significantly” affected his life, as he raised concerns that other hospitals using the equipment may not have trained staff properly.

“I have changed my perception of life,” he said. “I have scars that will last for the rest of my life, causing pain and discomfort.

“This equipment is used in lots of hospitals. That worries me. Are other hospitals using the equipment training their staff to use it properly? How could two previous patients have suffered minor injuries and not be noticed? How many other hospitals has that happened?

“I have no personal animosity for the individuals concerned. I know they have been personally upset by the incident. If I had been a child or a vulnerable older adult, we could have been talking about a death because of the seriousness of the burn.”

Malcolm Fortune QC, representing the trust, said the introduction of the hot dog equipment – which is no longer used by the trust – would have saved the organisation £250,000 over five years but he denied that it was brought in as a “cost-cutting exercise”.

The case had already cost the deficit-hit trust about £100,000 and a fine of between £200,000 and £300,000 should be considered, he added.

Mr Justice Sweeney said he would decide the amount the hospital will pay at Maidstone crown court next Thursday.

The judge told Wilcock: “I’m extremely sorry that you have undergone this very, very, very unhappy experience.”