Surgeon left needle tip inside baby during operation

[anonymouse007]

Hi everyone,

I'm hoping someone can advise me on my current situation. I'll avoid sharing too many 'outy' details but hopefully it'll be understandable.


My daughter was born with DDH (hip dysplasia). When she was 1 month old, we used a harness and fixed one hip. Her doctor decided she would need surgery to fix the second hip.

At 10 months old, she underwent an 'open reduction' surgery which involved making a cut, sorting out the hip socket and pushing her hip into the correct position.


My problem is this...
After the op, I was told the following by her surgeon--
When the stitches were done, my daughter's hip was x-rayed to make sure the positioning was correct. In the x-ray, a foreign object was noted in the hip joint. Doctors checked medical equipment and realised the tip of a suturing needle had broken off. They said it was "less than 1mm long." They re-opened her stitches but apparently couldn't find the piece and decided to leave it because it was "only in the tissue, not near the bone or muscle."
They said the piece will either "disintegrate" over many years or "be ejected from the skin as a foreign body" but it won't be harmful.


Honestly speaking, I feel like the issue was downplayed. The incident was not even mentioned on the discharge notes. I actually had to ask them to add it in (which they did) so that I would have it on record.
I also asked the nurses if an Incident Report had been filled out and if I could view it but I didn't get a straight answer. They told me to request my daughter's health records under the data protection act to find out more.
The surgeon did mention that they "will be contacting the needle manufacturers to ensure it doesn't happen again." That's all.


I just want to know...
Will my baby be OK?
Has anyone had a similar experience?
For other medics: have you heard of this happening? How serious would you say it is? Did the doctors/nurses act appropriately?
Should I seek legal advice?
What should I do?

I have many more appointments at the same hospital so hopefully I can ask questions next time I'm there. I'm just not sure where to start. Honestly, I just don't want this to affect my child's health or make her suffer in the future.


Thanks for reading my essay! Looking forward to hearing your opinions.

[iklboo]

They should record it as an incident or 'Never Event' for statistical data and reports to government. You should ask for a meeting for a full and frank discussion, apology etc. Start by writing to PALS.

[Nothappy16]

I also know someone who made a ‘near miss’ claim on something like this. I know that’s not something that’s tour first thought but this would ensure a full investigation is made into the process and the product of it was defective. Sorry you have been through this it must of been stressful.

[Skade]

iklboo has it - this is a Never Event (retained foreign object post-procedure), and there is no way they will get away without investigating it thoroughly. They will also have to submit their investigation report to the local CCG for scrutiny. See here (page 6):
improvement.nhs.uk/documents/2266/Never_Events_list_2018_FINAL_v5.pdf

Contact PALS and make sure that the hospital's Risk team are aware of the incident - they should be writing to you as a matter of course under the Duty of Candour requirement.

[anonymouse007]

@iklboo
Thank you, I'll ask them if they have done this when I'm there next week. I'll also contact PALS - totally forgot about them because I was just so shocked!
Thank you for the helpful advice.

@nothappy16
Hadn't heard of 'near miss' claims before but they do sound relevant here and yes, you're exactly right: what I want is a thorough investigation just to find out WHY and HOW this happened! A relative asked "Wow, were they stitching her up so roughly!?" and now this horrible thought/image of my little baby has been haunting me since
Thanks very much for your help.

[CherryPavlova]

It must be recorded and investigated as a never event.
The trust has a legal Duty of Candour under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
There is a requirement to provide a letter to you about the circumstances of the incident and the action taken.

In this case, there is unlikely to be settlement from the trust as they are not culpable. It is a medical devices issue and unless a trend has been identified by the manufacturer, it is unlikely to go anywhere.

Listen to the surgeon. It’s unlikely to create long term problems. Many, many people walk around very happily with random bits of metal or plastic in them from accidents.

[anonymouse007]

@Skade

Thank you so much!! I genuinely haven't heard of this before and I'm surprised the staff didn't mention this. I'll spend some time looking into this and make sure I have a list of questions for my next visit. You've been super helpful!

[anonymouse007]

@CherryPavlova
Thanks for your input - I'll be looking into this and the letter requirement is very interesting to note.

I honestly do hope the surgeon was correct and honest because the last thing I want/need is a legal battle or stress about my daughter's health. I'm just quite distrustful of hospitals due to 2-3 incidents that took place during my second daughter's birth (e.g. assault by a healthcare worker after I'd had a c-section). Fingers crossed my little one will be OK! That's all I genuinely want.

Thanks again for your help!

[iklboo]

Lots of luck.

[MissConductUS]

They re-opened her stitches but apparently couldn't find the piece and decided to leave it because it was "only in the tissue, not near the bone or muscle."

If they couldn't find it, how did they know it was "only in the tissue"?

[Juells]

Don't have any advice, just wanted to wish you well. What a horrible thing for you to have to deal with, and they've been bloody cavalier about it.

[Shoppingwithmother]

Missconduct - presumably they could see on the x-ray

[tenredthings]

They managed to leave a broken screw in my son's leg after taking a metal plate out, it's been a few years and he seems ok. No idea what the long term consequences might be !

[TheSheepofWallSt]

In terms of your daughters wellbeing- my uncle was in a very serious car crash in his late teens, and loads of very sharp metal and glass fragments were embedded deep in the flesh of his head and neck.

They randomly started to work their way out 20 years later- they looked like boils and when squeezed, the glass or whatever would pop out. Utterly grim, but harmless.

[Lougle]

I think it's important not to heighten anonymouse007's anxiety over this by passing comment on the attitude of the treating team when we have no evidence of their attitude. They haven't necessarily been cavalier, they have just said that in their opinion it is unlikely to cause harm (and a

[Motionoftheoceon]

Theatre manager here - firstly, this type of incident is very rare but does sometimes sadly occur. I don’t think it would be classified as a never event, the Trust medical director will make the final call on its classification, but given the remainder of the needle was accounted for and a 1mm fragment missing wouldn’t necessarily be able to be identified as visually missing. Regardless it will be a ‘serious incident’ and a panel should have undertaken an investigation and then reported its findings and any recommendations to the Trust and the local CCG. You would be within your rights to ask to see the report and meet to discuss it with someone, the best way to do this would be to contact the complaints team directly. They are very good at helping navigate those patient / clinician conversations.

Regarding the issue of long term implications. There is merit to what the clinical says, very often going ‘digging’ for a very small fragment can be very damaging to the surroundings tissue and be more detrimental to leaving it where it is. We have certainly knowling made a similar decisions when fragments have broken off a drill piece. That being said there is always a risk with leaving behind a small object, but it will be relatively small if located in soft tissue, it will act like a deep splinter and if you haven’t experienced any issues you’re not likely to now.

I think it sounds like they glossed over it a bit at the time, and if you think it would help I would ask to speak to another senior orthopaedic surgeon to get a second opinion.

Don’t feel afraid to raise the issue even if it’s been some time, I certainly wouldn’t mind if it crossed my desk and would take the time to give a full account to help everyone feel well informed and that the issue had been dealt with transparently.

[Juells]

I think it's important not to heighten anonymouse007's anxiety over this by passing comment on the attitude of the treating team when we have no evidence of their attitude. They haven't necessarily been cavalier

anonymouse007 is obviously well clued in herself, as she says
Honestly speaking, I feel like the issue was downplayed. The incident was not even mentioned on the discharge notes. I actually had to ask them to add it in (which they did) so that I would have it on record.

[isshoes]

I am not a medical professional nor do I work in healthcare, but reading that document linked to by a PP, I don’t think this would be classified as a ‘Never Event’ because of the following exception listed on page 7:

are known to be missing before completion of the procedure and may be inside the patient (eg screw fragments, drill bits) but action to locate and/or retrieve them is impossible or more damaging than retention.

[Cel982]

As a doctor, OP, I'd say confidently that a

[Racecardriver]

Try not to worry too much. It’s unlikely to be a problem for her. This must be so stressful for you I hope that you get some answers and find the reassuring

[Knitwit101]

I'm sorry you're having to think about this after all your baby's surgery, you really don't need that, even if it is harmless. I hope the surgery worked out well for her and her hip is now sitting ok.

[OlennasWimple]

Not a medical professional, but I doubt that this was caused by them treating your baby roughly. I understand that this has been an upsetting incident, but it'snot helpful to worry about things that (almost certainly) didn't happen - focus on what actually did and what you can do to help ensure it doesn't happen again

[prh47bridge]

isshoes - No, that exception does not apply. The "procedure" was the surgery. The item was not found to be missing until they found it on the x-ray. If they had found that the tip of the suture needle had broken before the surgery was finished this exception might apply. They didn't so this is, as others have said, a Never Event.

[mcmooberry]

Hi, I think they did the right thing not spending a prolonged time looking for it (literally a needle in a haystack) at less that 1mm long and not in the hip joint itself, the safest thing was to let her recover and they could have caused more trauma to the area by digging around looking for it. Totally understand why you are worried for her and of course it's a very unfortunate thing to happen but I would believe the surgeon that she will in all probability be absolutely fine.

[isshoes]

@prh47bridge do you say that based on actual knowledge or is it an assumption? If it’s the former, I stand corrected. If it’s the latter, I disagree. The OP said this was what the surgeon told her after the operation. It sounds to me like the x-ray was done immediately after the stitches, before the whole procedure was completed, and they attempted to find the needle tip whilst they were still in theatre.

[Lougle]

prh47bridge the post-fixation x-ray will be part of the Standard Operating Procedure for that surgery, and the surgery will only be deemed to be over once the surgeon is happy that the hip is in position, etc. Therefore, I would be almost certain that this x-ray would be classed as intraoperative, even though the wound was stitched. Just as, if that x-ray found the hip to be malpositioned, the subsequent positioning wouldn't be a "re-do" second surgery, it would be an extension of the original surgery.