Saturday, 16 October 2010

"Ah, my children of the NHS. What beautiful music they make..."

A pensioner died after his chest was bled 'empty' when he was wrongly connected to a blood pumping machine and a hospital worker left the room.
NHS staff failed to use enough clamps to disconnect 76-year-old Dr John Baines from the device after a gruelling six-hour bypass operation, on January 29.
This meant his blood was pumped into the machine, which was filling in for his heart and lungs during the surgery, but not pumped back into his body.
Someone will swing for this, surely?
Deputy Assistant Coroner Mairin Casey ruled that no one member of staff was to blame and his death was caused by a 'series of collective errors'.
In a bypass operation, the pumps are operated by specially trained health professionals known as 'perfusionists', who work with the surgical team in connecting and disconnecting the machine to the patient.
However, the perfusionist who had been involved in the discussions about the complex operation was replaced before it began by two others, who oversaw the machine during the surgery.
One of them, Andrew Sutcliffe, said they clamped the line from the patient's neck and assumed two other clamps required had been attached by other members of the team.
He said: 'I think the issue is that we had clamped the common line. But clamps hadn't been applied where we would have expected them to.'
And you didn't think to check? Somehow, 'professional' isn't the word I'd have used...
Miss Casey recorded a narrative verdict and said the mistake was the result of collective rather than individual error.
She said: 'I'm confident that from the earliest point the human error was acknowledged to the family and to all who needed to subsequently investigate this matter.
'I'm also satisfied that there's no culpability in respect of an individual in this case.'
Nice! In effect, so many of you screwed up it'd be 'unfair' to hold any one of you responsible, so you get off with a massive fine (paid for by us taxpayers, of course) and a 'lessons have been learned' statement.


Macheath said...

'...assumed two other clamps required had been attached by other members of the team.'

I've always loathed corporate-training-day speak such as 'assume makes an ass out of you and me' but in this case, it might actually have been a useful mnemonic.

Perhaps it should be writ large on the walls of every operating theatre (along with 'Are you sure you've counted the swabs?')

(BTW, black humour it may be, but even by your standards, the title is inspired.)

JuliaM said...

Cheers! I hope everyone got the reference :)

killemallletgodsortemout said...

....was acknowledged to the Family...

"Oh, Hi-i.

Just to let you know that we've killed your relative. This was done by human failure - we all had a hand in it, so none of us are guilty, OK?

If you want to see him before he goes to the mortuary, you need to get your skates on, as we have to have a mandatory refreshment break, now that we've all been traumatised by his death.

We might - just might - need to sue you as well. It's the stress, you see.



Henry North London 2.0 said...

NHS NO Health Service