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Thursday, 12 September, 2002, 15:25 GMT 16:25 UK
'Human error' led to op mix-up
Prince Charles Hospital, Merthyr
Bone surgery at the hospital is to restart on Monday
An investigation has revealed human error was to blame for a mix-up during an orthopaedic operation at a south Wales hospital.

The patient Annie May Carter, 59, later died but there is no suggestion of a link between the bungled surgery and her death.

Bone operations at Prince Charles Hospital in Merthyr Tydfil were cancelled as a result of the mix-up during which a right knee part was inserted into her left leg by mistake.


I was pleased to be advised that this orthopaedic team can resume operating duties

Medical director Dr Terence Morris

The mistake led to theatre procedures at the valleys hospital being investigated by a Royal College of Surgeons consultant orthopaedic surgeon on Tuesday.

As a result of the human error finding, the hospital has been given the all-clear to resume emergency orthopaedic surgery on Monday but non-urgent operations will not be booked for another two weeks.

Mrs Carter, who had acute angina, died 11 days later on 31 August in the University Hospital of Wales, Cardiff, after suffering three heart attacks at her home.

About 40 planned orthopaedic operations at the hospital have been postponed during the suspension with a further 80 in the pipeline put back.

Mrs Annie May Carter
Mrs Carter died after suffering three heart attacks

The hospital has now instigated new procedures to try and stop such a mistake happening again, including an immediate update of it storage and stocking methods.

The RCS consultant also commented on the need for clearer labelling of prostheses, a point the hospital's governing NHS trust said it would take up with the manufacturers, as this would help orthopaedic teams throughout the health service.

The hospital's medical director, Dr Terence Morris, said on Wednesday: "I was pleased to be advised that this orthopaedic team can resume operating duties at Prince Charles Hospital.

Prince Charles Hospital, Merthyr
Around 120 operations have been affected

"There remains a problem with overall staffing levels due to vacancies and leave and as a consequence patients will not be booked for planned operations for another two weeks although the position will be kept under continual review.

"However, all emergency orthopaedic operations will recommence from Monday next, 16 September."

An inquest last week into the death of Mrs Carter, from Gurnos, Merthyr Tydfil, was adjourned until further investigations are completed.

 WATCH/LISTEN
 ON THIS STORY
BBC Wales' Melanie Doel
"First staff didn't read the box containing the parts and then they failed to follow a verbal checking procedure."

More news from south east Wales
See also:

31 Aug 02 | Wales
10 Jan 02 | England
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