A hospital in Stoke-on-Trent has carried out three wrong site surgeries in as many months – and bosses still do not know why it keeps happening.

The three 'never events' at the Royal Stoke University Hospital all involved incorrect lesions being removed from patients during surgery.

After the second incident was reported in February, the hospital launched a 'deep dive' into the problem to see what lessons could be learnt to prevent similar never events happening again. But despite staff believing that they had considered everything and put in place adequate countermeasures, a third wrong site surgery happened in March.

Chief nurse Anne-Marie Riley told a meeting of the University Hospital of North Midlands trust board that further work was being carried out to address the issue. She said: "After the second incident, they believed at that point they had put in every intervention across the board that would prevent this happening again, but clearly it didn't. So we need to look at every option again, internally and externally, just to see if there is an issue, or if there's something happening on those occasions in particular that we haven't thought of as part of those countermeasures.

The three incidents all involved incorrect lesions being removed from patients (SWNS).

"The team did a really intensive piece of work, looking at very specific checkpoints to stop this happening again, but clearly something has failed, and we need to understand why."

A report on the latest wrong site surgery states that the patient attended an appointment on February 19, following a referral for a lesion on his scalp. But during the appointment, the doctor reviewed a old referral from 2021 which was in relation to a lesion on the patient's neck, which had been treated at the time.

This resulted in the patient attending the dermatology theatre on March 7 and undergoing a punch biopsy on his neck. The mistake came to light the following day when the man's daughter contacted the department to raise concerns that the wrong lesion had been operated on.

The first incident took place on 29 January, when the wrong scar was excised (Image supplied).

The first incident to be reported took place on January 29, when a patient attended the dermatology department for a wide local excision on a scar. The following day he contacted the department as he believed the wrong scar had been excised, and it was subsequently found that the surgeon had removed an old scar from an excision the patient had in 2017.

Another wrong site surgery involving an incorrect lesion was carried out on January 11, but was only reported after the patient was discharged from hospital the following month. A report to the trust board states that a thematic review will compare any differences or similarities between the never events, and make recommendations on how processes could be improved to reduce the risk of future incidents.

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READ MORE: Extra cameras to be installed in a Stoke-on-Trent town centre

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