Published: 00:01, 17 May 2018
| Updated: 08:39, 17 May 2018
An investigation by the KM Media Group has revealed some of the biggest blunders made by the NHS in Kent in the past two years.
From the start of 2016 until January 19 this year, 71 "serious incidents" were recorded by Kent Community Health NHS Foundation Trust (KCHFT).
Serious incidents are events in which the consequences to patients, families and staff are so significant that they require an investigation and comprehensive response, or for lessons to be learned.
In the two-year period investigated, KCHFT reported incidents ranging from confidential documents being left in public toilets, to a patient having the wrong tooth pulled out.
Bedsores are one of the most common serious incidents affecting patients in the county, data obtained under the Freedom of Information Act has shown.
Severe bedsores, or “advanced pressure ulcers” can cause extreme pain.
The most serious of these - graded 3 and 4 - can involve horrific wounds so deep that they reach layers of muscle and bone.
People confined to a bed or chair are at particular risk of developing these open sores, as they are caused by prolonged pressure on the skin.
They were found to account for 32 of the total serious incidents, with the majority forming on patients’ feet, buttocks and lower back.
During the period investigated, one unfortunate child also had the wrong milk tooth pulled out, while another young person was mistakenly given a flu vaccination.
This was administered in the form of a nasal spray by an immunisation specialist visiting the child’s school, despite the fact a parent had stated on a consent form that they did not want their child to receive it.
Some serious incidents go beyond botched procedures and patient injuries, instead covering other, non-medical problems.
Twice in two years, confidential patient information has been found lying around in public areas.
Once, documents were found in public loos at a healthcare facility, while on another occasion 20 patients’ records mysteriously ended up in an alleyway.
Fortunately, these documents made their way back to safe hands and no information is believed to have been leaked.
Chief Nurse Ali Strowman said: “Firstly, I’d like to apologise to anyone who was affected by any of these incidents - we have contacted everyone and explained what happened and why.
“Delivering healthcare doesn’t come without risks and while we always aim to give the highest quality of care, with three million patient contacts every year, we’re sorry we don’t get it right every time.
"One of the most important things is we learn lessons to reduce the risk of similar incidents happening again" - Ali Strowman
“We fully investigate every incident with involvement from our patients and their family to make sure we have the full picture of what happened, and how we can learn from the incident.
"We share our reports with families and always offer to meet with them to make sure they fully understand the actions we are taking.
“We are open and honest when mistakes happen. One of the most important things is we learn lessons to reduce the risk of similar incidents happening again.
“These incidents took place during a two-year period and while one is one too many, we know that our services do not have more incidents than other providers of a similar scale.”
Responding to concerns about incidents of pressure ulcers, she said: “We’ve made great strides in reducing pressure ulcers in the past year, achieving a 21% reduction in the grade three and four, and a 37% reduction in grade 2.
“We have developed an app, which photographs and measures wounds to support faster healing, and ran a campaign last summer to raise awareness of the steps people can take to reduce their risk.”
Kent Community Health NHS Foundation Trust provides care in a range of settings including nursing homes, health clinics, hospitals, and people’s own homes.
The Trust - which is rated ‘good’ by the Care Quality Commission - runs facilities across the county, and is one of the UK’s largest community health providers with about three million patients each year.
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