Kidney blunder hospital criticised

The Welsh Assembly asked for the CHI inquiry

The hospital at which a patient's healthy kidney was removed by mistake has not tightened its procedures quickly enough, an official inquiry has concluded.

NHS inspectorate, the Commission for Health Improvement (CHI) was called into investigate procedures at Carmarthenshire NHS Trust in Wales earlier this year.

It followed the case of 70-year-old Graham Reeves who died in February after surgeons at the Prince Philip Hospital in Llanelli removed a healthy kidney instead of a diseased kidney by mistake.

The Commission said on Wednesday that the Trust had drawn up an action plan to address the problems but had been slow in implementing it.

Peter Homa: Criticised the Trust

CHI chief executive Peter Homa said: "While we cannot be specific about the failures that led to Mr Reeves's death, we can say that the Trust's action plan addresses the right issues, but is taking longer to implement fully than it should."

The death of Mr Reeves is still being investigated by police and the CHI inquiry centred on overall procedures at the hospital rather than the individual case.

The Royal College of Surgeons and the Trust, which runs the hospital where the mix-up took place, have already carried out investigations into the incident, but their findings have not been released.

The CHI report raised wider concerns about the running of the Trust. These included:

outdated ways of managing nurses.

inappropriate admissions to the Prince Philip's A and E Department, despite an agreement that this should not happen.

no executive director of human resources and

failure to share policies and procedures in operating theatres which poses "a significant risk".

Urgent action

Mr Homa said urgent action was needed to overcome these problems.

"The broader issues CHI addresses about the Trust, like the wrong patients being received in the A&E at Prince Philip Hospital, needs tackling as a matter of urgency.

There were no surprises for us in this report and we make no excuses

Mike Jones, Carmarthenshire NHS Trust chief executive

"If the Trust carries out all our recommendations, local people can again have confidence in the services it provides," he said.

Mr Jones attributed "shortcomings in organisation and procedures" to a Trust merger in 1999.

The report also reveals that staff at the Trust remain confused about how to handle criticial incidents.

It found that the two hospitals that make up Carmarthenshire NHS Trust - the Prince Philip Hospital in Llanelli and the West Wales General Hospital in Carmarthen - were struggling to work as one.

It criticised the lack of a single overall programme for improving patient care.

CHI said reports by the Trust and Royal College of Surgeons into Mr Reeves's death would not yet be made public because the Trust had been advised an inquest had not been completed.

'No surprises'

Carmarthenshire NHS Trust chief executive Mike Jones said the report contained no surprises. He said the shortcomings it highlighted were already being addressed.

In a statement he said: "Carmarthenshire NHS Trust welcomes the publication of the report of the Commission for Health Improvement, which has highlighted a number of issues for our attention and action.

"In general terms there were no surprises for us in this report and we make no excuses.

"It pinpoints some shortcomings in organisation and procedures, of which we were already aware, largely brought about as a result of the merger in 1999 of two existing NHS Trusts to create Carmarthenshire.

"In coping with reorganisation, Carmarthenshire has faced the same management issues as other Trusts during a period of immense change in the NHS as a whole.

"While we were already taking steps to remedy our particular issues as part of an ongoing reorganisation programme, we are grateful to have an outside, independent perspective."

Denzil Davies, MP for Llanelli, who attended today's CHI briefing, said the report did not go much towards explaining the death of Mr Reeves.

But he added: "In our area there was a merger between two hospitals with completely different backgrounds. "The lesson is not to have mergers unless you work it out beforehand and really know what you are doing."