On June 10, 2013 a 32-year-old “heavily” pregnant woman was reported to have died after having an ovary removed instead of her inflamed appendix. As the infected appendix festered, she became septic and succumbed to multiple organ failure. This tragedy occurred in the UK in late 2011, but has just come to light.
How could this have happened?
Let me count the ways.
The surgery was performed by two trainee surgeons. Their level of experience was not stated.
The senior staff, called consultants in the UK, had gone home for the day.
The operation to remove the appendix was apparently done as an open procedure, not laparoscopic, which is acceptable if done correctly. The articles say that the surgeons had to take out the organ by feel and not under direct vision, which is not proper.
Although an ovary can be enlarged during pregnancy, under no circumstances does an ovary look or feel like an appendix. As in another case described below, inflammation can cause confusion at times, but not to this degree.
The woman was discharged a week after the initial surgery but returned with pain some 10 days after the removal of the wrong organ. During that time period, no one had checked the pathology report. The mistake was discovered by a doctor reviewing the patient’s records during the readmission.
An abscess was drained but the she died on the operating table during a futile attempt to at last remove the appendix.
Last week, the CEO of the hospital sent a written apology to the family promising to correct the dreaded “system errors.” Too little, too late.
Yes, there were system errors.
But what about human errors?