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17 May 2019
Manchester Royal Infirmary admits blood error on man with haemophilia
A haemophiliac who was given the wrong blood clotting medication during revision hip surgery at Manchester Royal Infirmary (MRI), despite it being a specialist centre for blood disorders, says lessons have to be learned by the hospital or more patients will be harmed after the hospital trust admitted negligence.
Seventy-one-year-old Roger Kirman of Cheadle Hulme, who was given Hepatitis C from the NHS infected blood scandal of the 1970s and 80s and was only cured the year of this operation, was left devastated by the blunder at the MRI. He had moved to Manchester so that his care could be provided there due to its reputation as a centre of excellence for haemophiliacs.
The error caused his blood clotting levels to fall dangerously low following the operation and caused a significant bleed in his thigh. Worryingly, the incorrect medication had been checked by several different nurses, who also consulted doctors. The mistake was remedied eight hours later when a specialist haemophilia nurse came on duty and noticed a discrepancy with the medication stock. She raised the alarm and gave the correct clotting Factor.
In October 2018 the surgical unit at the MRI was inspected by the Care Quality Commission (CQC) and was told it needed to improve. Issues the CQC found included not consistently complying with the surgical safety checklist, poor management of infection prevention, higher than average readmission rates and taking too long to deal with complaints. The findings from the CQC have led Roger to question whether lessons have been learned from his case as he fears other patients may suffer the same blunders as he has.
Roger says he has been left with problems walking because the bleed he suffered. He says he has stiffness and a constant pain when walking and cannot use a stick to help him because of joint pain it causes in his left arm due to his haemophilia. He says he now also has poor balance. The hospital trust has now admitted the error and that it caused him to suffer an extended bleed after a legal case was brought on Roger’s behalf by specialist solicitors at law firm JMW. However the trust denies that its failure has caused Roger ongoing problems.
Roger decided to take legal action against the trust in a bid to hold it to account and stop the same mistake from being made again after fearing for the safety of other surgical patients, particularly those with complex needs. After making an official complaint to the trust he did not feel satisfied that those at the helm had fully grasped the serious nature of the error.
Roger, a father of three daughters and grandfather of three, commented: “I have had numerous operations throughout my life due to the impact the haemophilia has on my joints but this was the worst hospital experience I have ever endured.
“I am very upset about the error especially when bearing in mind Manchester Royal Infirmary is supposed to be a centre of excellence for haemophilia patients. I would have thought that all staff on the wards involved with my care would have been aware of the nature of haemophilia and the medication used to control it.”
“The individual staff members bear some of the blame but I really feel there is an issue with management at the hospital not learning from mistakes and ensuring things are done properly. Following the error and our complaint, an inadequate investigation required a second detailed review which exposed a sequence of failings. I believe the management is unable to provide the level of care required to safely treat patients with complex needs. They need to understand the impact errors have on patients and their whole family. I’m now slower than I was previously and that does have a knock-on effect on my quality of life and time with my grandchildren.”
Nick Young, a specialist medical negligence solicitor at JMW who is representing Roger in his legal battle, commented: “This error should never have happened and it is extremely concerning that a patient with a well-known condition cannot put faith in medical staff to know how to ensure their safety during surgery.
“The problems with surgical safety at the MRI are outlined in the critical CQC report. The findings were extremely disappointing and frustrating for Roger who sees that the problems were continuing despite him raising his concerns via the hospital’s complaint process.
“What managers have to realise is the serious implications these errors have on individual lives. I hope that following this admission of negligence the chance of another haemophiliac suffering such a dangerous error has been reduced.”
Roger’s hip surgery took place on the afternoon/evening of 21 June 2016 and went well until he was given the wrong blood clotting medication, post-surgery.
Roger remained in hospital under observation until 5 July. However almost three years on from the operation Roger says the bleed he suffered as a result of the medication error has left him with pain and stiffness in his leg which makes walking difficult for him.
Following the hip surgery Roger should have begun anti-viral treatment for the Hepatitis C he was given in the NHS infected blood scandal. This was planned for September 2016 but he was not considered fit enough. The treatment was further delayed and it actually began in the November. It was around May 2017 that he was given the all clear.
For more information or to arrange an interview, please contact Kelly Hindle or Samantha Meakin on the details below:
D. 0161 828 1868
Note to Editors
JMW Solicitors LLP is a leading Manchester law firm and offers a broad range of legal services to both commercial and private clients.
JMW’s Clinical Negligence team is headed up by leading clinical negligence lawyer, Eddie Jones.