Maidstone and Tunbridge Wells NHS Trust fined £180,000 after patient suffers debilitating burns from super-heated mattress
19 December 2014
A sedated patient suffered a debilitating injury when a saline bag caused a warming mattress to reach temperatures high enough to cause full thickness burns, a court has heard.
It is believed the bag was inadvertently placed on a sensor intended to monitor the mattress temperature, providing an inaccurate reading that prompted the equipment to continue heating.
Mike Wilcock, 56, awoke from a minor operation with third degree burns to his hip and buttock as a result of the incident at Maidstone Hospital on 25 September 2012. As he had been under anaesthetic, he had been unaware of what was happening and was therefore unable to alert medics.
On 18 December, Maidstone and Tunbridge Wells NHS Trust was ordered to pay almost £195,000 in fines and costs after an investigation by the Health and Safety Executive (HSE) identified failings with the way the warming equipment was used.
Maidstone Crown Court was told that Trust staff did not have sufficient information and training to ensure the heated mattress was used in accordance with the manufacturer’s instructions.
Mr Wilcock required skin grafts at a specialist burns unit. He was unable to work for almost five months and also suffered a mild heart attack that was likely to have been attributed to the successive operations.
The qualified sailing instructor has been forced to curtail the hobby he loves because he is no longer able to sit in a boat, and has been left with permanent scarring.
Maidstone and Tunbridge Wells NHS Trust was fined a total of £180,000 and ordered to pay a further £14,970 in costs after admitting breaching Section 3(1) of the Health and Safety at Work etc Act 1974.
After the hearing HSE inspector Dawn Smith commented: "Mr Wilcock suffered a serious debilitating injury that was entirely preventable had the Trust implemented a better system and procedures to ensure the warming mattress was used correctly.
"While the precise circumstances of what happened are somewhat unusual, it is entirely foreseeable that failing to ensure that staff know how to use a piece of equipment may have a negative outcome.
"The risk of injury from warming devices is well documented, and it also well known that anaesthetised patients require extra care and attention because they are not able to respond and react as they ordinarily would.”
Mike Wilcock said: "What should have been a simple operation has left me disfigured and has disrupted my life and that of my family. My case highlights the critical nature of suitable and adequate training for staff in how to use and maintain equipment. It also highlights that even with the most dedicated staff in the world things can go wrong, and when they do it is absolutely vital that a full and open investigation is carried out and that lessons are learned.”