Transplant patient sent home from hospital with A4-sized surgical mat still inside him
Michael O'Sullivan, 49, had a CT scan three weeks after his liver transplant after he complained of painA second operation revealed that a silicone mat had been left inside him during the earlier operationIt was a 'never event' – a hospital incident that should never happenLawyer who won him 7,000 compensation said it had been 'basic carelessness'



20:36 GMT, 4 December 2012

A liver transplant patient was sewn up with an A4-sized piece of surgical equipment left inside him, after a series of medical blunders.

Michael O'Sullivan, 49, received a new liver at Addenbrooke’s Hospital in Cambridge, but was sent home with a silicone mat still inside him.

It was only discovered after Mr O'Sullivan complained of suffering from a lot of pain following surgery. Doctors performed a CT scan three weeks later and decided to operate after spotting something unusual. Mr O'Sullivan was shocked to be told they had discovered the equipment inside him following the operation.

Surgeon and assistant performing operation (posed)

Surgeon and assistant performing operation (posed by models)

He has now won 7,000 in compensation from the Cambridge University Hospitals NHS Foundation Trust.

The award comes after Addenbrooke’s was heavily criticised by health watchdog Monitor, which cited a series of so-called ‘never events’ – incidents that simply shouldn't happen – as one of its major failings.

Personal injury lawyers Slater and Gordon said the ordeal had been 'incredibly stressful' for their London-based client and could have put his health at risk.

Mr O'Sullivan had a lapromat – a fish-shaped piece of silicon
– inserted during surgery just before closure of the abdominal wall and
designed to prevent inadvertant puncture of the bowel.

The lapromat acts as a
kind of protective shield and should be removed before surgery is

Addenbrooke's Hospital in Cambridgeshire

Mr O'Sullivan was treated at Addenbrooke's Hospital in Cambridgeshire (pictured) which has been criticised by the health watchdog Monitor

Paul Sankey, Principal Lawyer at Slater and Gordon, told Mail Online: 'The hospital's own investigation says that the cause of the incident was
the failure correctly to record that an item from the instrument set
was in use, not recognising that it had not been removed and failure
correctly to complete the count at the end of the procedure.

'The normal
rule is – count in, count out. The root cause was said to be the
breakdown of routine checking procedures. In other words this was not,
like most surgical mistakes, an error of judgment in the exercise of a
difficult skill but really basic carelessness.

'I deal with medical
negligence claims day in day out. In my experience mistakes quite as
blatant as this are extremely rare.'

A fish-shaped lapromat, like the one pictured, was left inside Mr O'Sullivan

A fish-shaped lapromat, like the one pictured, was left inside Mr O'Sullivan

Rebecca Brown, from the same firm, added: 'When we go to hospital for surgery, we
rightly expect the highest standards of healthcare and professionalism.
These standards were not upheld when Michael had his liver transplant at

'The award of compensation is a relief for someone whose health could have been endangered by this carelessness.

'We hope that the resolution of this
case, as well of those of others who have brought actions against
Cambridge University Hospitals NHS Foundation Trust, will serve to
protect patients in the future.'

A spokesman for Addenbrooke’s said: 'We deeply regret this incident and have apologised to the patient.'


Dr Dan Poulter said the new rules will increase patient confidence

Dr Dan Poulter said the new rules will increase patient confidence

Healthcare providers will be contractually obliged to admit when they have made medical blunders that put patients at risk, it has been announced.

From April next year NHS organisations will be forced to be transparent about breaches of patient safety, Health Minister Dr Dan Poulter said.
The new rules will increase patient confidence, he said.

Ensuring staff across the health service are truthful is 'crucial' to delivering the highest standards of care, he added.

At present, the NHS is expected to be truthful about mistakes but there is no contractual obligation to stop cover-ups.

'Patients place great faith in the NHS organisations that treat them, and they in turn have a duty to be honest and open about every aspect of care they deliver,' Dr Poulter said.

'When mistakes are made, we want them acknowledged, patients informed and lessons to be learnt.

'The importance of an open culture cannot be underestimated. We expect that Robert Francis will make further recommendations on the duty of candour when the Mid Staffordshire Inquiry is published, and we are committed to taking whatever further action we think is needed as a result.

'But we cannot wait – creating this contractual duty of candour now ensures that NHS contracts for the next financial year will champion patients’ rights to basic honesty, as well as safe care.'

Peter Walsh, chief executive of the charity, Action Against Medical Accidents or AvMA, said: 'This appears to be a cynical attempt by the Department of Health to sidestep overwhelming pressure from patients’ groups and others for a statutory duty of candour and pre-empt recommendations from the Mid Staffordshire Inquiry which are likely to recommend a statutory duty.

'No one should be taken in by this. We do not object to a standard clause in NHS trusts’ contracts, but what the Government is saying is that it does not see a duty of candour as one of the ‘essential standards of quality and safety’ which all health organisations need to satisfy in order to be registered with the Care Quality Commission (CQC).

'It clearly should be, as this would give the CQC statutory power to insist upon and enforce it. It is simply wrong to relegate such a fundamental issue to a standard clause in NHS trusts’ contracts.'