RARE NEGLIGENCE

Evening Post, Volume CXII, Issue 107, 2 November 1926, Page 3

RARE NEGLIGENCE

FORCEPS LEFT IN PATIENT

RESPONSIBILITY AT OPERATIONS.

(From Our Own CorrMpondtgit) LONDON, 25th September. The name of a New Zealand medical man was mentioned at an inquiry this week, touching the death of Mrs. Florence Annie Tapp, aged 47, St. Mark/« road, Fulham, who died at St. George's Hospital on 17th September. For three years she had lived with a pair of forceps six inches long, in the pelvis, the instrument having been overlooked by; the surgeon after an operation. The husband said that three years ago his wife underwent an operation at St. George's Hospital for the removal of a cyst. A fortnight ago ''she told him that she could feel a piece of wire in her inside. Two days later she was taken to St. George's Hospital, and while she waa there he received an. anonymous letter, which read: "I think it right for you to know that I heard a night nurse telling another nurse that your wife had a pair of scissors left in her stomach after her operation.'' He was told about the forceps at the hospital before he received the anonymous letter. ' ■ Dr. B. A. Burns, resident assistant surgeon at the hospital, produced the notes of Mrs. Tapp's case three yean ago. She was admitted on 16th December, 1923, for immediate operation. This v/as done, and she recovered, and was discharged a month later. On 15th September this year an operation was performed, and. a pair of Littlewood'i forceps were found. They were six inches long, and were broken, but the parts were held together. The patient progressed favourably, and it was hoped Ithat she would make a recovery, but she died on the .17th instant. Dr. H. B. Weir, who made the postmortem examination, said that death' was due to peritonitis following the operation for the removal of a. foreign body from the intestines. He had read of such cases, but.had never seen. one. At St. Thomas's the custom was to hold a sister responsible for seeing after all the instruments of an operation. The surgeon, however, was responsible for everything, and he could not condone a surgeon leaving a pair of forceps behind. .. ■ ' . . .-,. COUNTING INSTRUMENT*. Dr. George K. Thornton, medical officer of the Queen's Hospital for Children, said he remembered assisting in. the operation three years ago. About a dozen forceps were used. It was the custom for the chief operating surgeon to count the instruments, and it was the "present practice. The Coroner (Mr. Ingleby 6ddie)f "If an instrument was left behind, your view is that it is the surgeon* own fault?"—" Yes." "I don't want you to condemn a colleague, but what is your view about this accident?"—"lt certainly ought not to have arisen. I have never known it to happen before." The Coroner remarked that he had made inquiries at other hospitals regarding the practice adopted, because it was not the first case'he had heard of. He found that the practice at every hospital was that an assistant was responsible for the instruments, counting them before use and afterwards, and reporting that all was correct, but that responsibility rested with the surgeon; He recorded a verdict "That death was due to peritonitis, following an operation for the removal of a pair of artery forceps, negligently left behind during an operation for tin removal of- a cyst, and I further say that the said negligence was not grosi and culpable." ■