Mother and Grandma Reveals Months Of ‘Agony’ After Having Wrong-Sided Implant Fitted

A woman has revealed how she was left in ‘agony’ for several months after a hospital wrongly fitted a right-sided implant during replacement surgery on her left knee.
 
Barbara Barnes, of Congleton, had the wrong side implant fitted at Macclesfield General Hospital in October 2018. An internal hospital investigation found that the different sided joints were stored in a box together. The right-sided joints were stored in the left of the box and the left-sided implants were on the right, it added.

Following this, Barbara instructed expert medical negligence lawyers at Irwin Mitchell to investigate her care under East Cheshire NHS Trust, which runs Macclesfield Hospital.

Barbara, aged 74, and her legal team urge the Trust to ensure it upholds new policies introduced following her case to improve patient care.

It comes after the Trust admitted that there was a failure to insert the correct sided implant in Barbara’s knee and acknowledged that the mum-of-four and grandmother-of-seven will require corrective surgery.

Barbara said: “I had been struggling with my knees for years, so getting the green light on the replacements was exciting. However, after the first procedure something just didn’t seem right.

“I was extremely worried that something had gone wrong, but kept being told that everything was fine.

“Being told that a right-sided implant had been used on my left knee was a huge shock. It’s the kind of basic error that you would not expect when undergoing major surgery. I still can’t believe it happened.”

She added: “The issues raised by the investigation were very concerning, but it is at least welcome that measures can be taken to prevent this from happening to anyone else.

“You put a huge amount of trust in doctors and something like this impacts on that massively. I just hope that the NHS prevents this issue from happening again.”

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Background

After suffering with knee problems for many years it was decided Barbara, who is married to John Barnes, aged 73, would undergo a double knee replacement starting with her left knee.

After undergoing surgery in October 2018 she complained for several months about still being in pain, despite physiotherapy sessions.

In January 2019 the National Joint Registry, the body which monitors performance of replacement implants, contacted East Cheshire NHS Trust concerned about irregularities in four cases. Following a review, the errors in Barbara’s case were identified. The other three cases were identified as inputting errors.

A Root Cause Analysis Investigation Report by East Cheshire NHS Trust found that the type of implant Barbara had were stored together, with left-sided items on the right side of the box, and right-sided items on the left.

The Trust also said how it was standard practice for three checks to be carried out on a prosthesis – firstly by a member of the theatre team who collects the prosthesis from the storage room, then by scrub nurse and thirdly by the surgeon. Staff would present the devices and state what it was independently.

Concerns were raised that this approach may lead to ‘confirmation bias’, with those who subsequently check the device assuming that the first one is correct. The Trust deemed that the checking process was not robust enough.

East Cheshire NHS Trust has confirmed that storage arrangements had been changed, including storing different sided implants in different colour coded boxes. The checking procedure in theatre has also been amended to ensure the doctors and scrub nurses read the information on the item.