Mr Johnson underwent a nine-hour operation involving four separate procedures at the Glenfield Hospital, Leicester, on the 13 January 2009. During surgery it was discovered at a primary swab count that three surgical swabs measuring 10 x 7.5 cm were missing. Two swabs were found but the third remained unaccounted for. A lack of communication from scrub nurse, Krishna Rungen, meant that Mr Mark Hickey, Consultant Surgeon, was allowed to close the wound and finish the operation with the swab still inside Mr Johnson’s chest.
Mr Hickey was called during the evening following the surgery and was informed of the missing swab. It was decided not to take any action that evening because the position of the swab had not been seen on x-ray. Unfortunately, Mr Johnson’s condition deteriorated and on the 19 January 2009 a further chest x-ray confirmed the position of the swab. Mr Hickey elected to re-open the wound to retrieve the swab on the 20 January 2009. Sadly, Mr Johnson died on the morning of the 22 January 2009.
Catherine Mason said “Mr Johnson died as a result of multiple organ failure which had in part been caused by a surgical swab being left inside his chest during cardiac surgery on January 13, 2009. Procedures were in place at the time to prevent this happening but they were not followed.”
Catherine Mason will now write to NHS bosses and the Lord Chancellor to raise concerns about staff shortages at the hospital which may have been partly to blame for the mistake.
Sally-Ann Robinson of Langleys represents Mr Johnson’s family in investigating the treatment Mr Johnson received at the Glenfield Hospital. The family released the following statement following the inquest:
“The family would like to thank Her Majesty’s Coroner Mrs Mason for her very thorough investigations surrounding Mr Johnson’s death as within her power.
It is clear that procedures were not followed which should have ensured that the missing swab was not left inside Mr Johnson’s body at the end of surgery.
The family have really appreciated the honesty of the Trust after the event in admitting their mistake, and their support of those affected by this sad loss.
What is important for the family today is that the Coroner’s intention to raise the evidence of shortcomings in practice and procedures that were influenced by inadequate staffing levels is acted upon. The best memorial for Mr Johnson would be that changes should be made to ensure that no family has to go through what they have done.”