Recurring concern

Unreliable pre-operative preparation and safety checks

First to latest report 19 Dec 2013 — 17 Jan 2018

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
7

What this concern includes

Includes failures of pre-operative preparation and safety-check arrangements, including patient preparation, inspection and functional checks of operating-theatre equipment, staff competence for those checks, and assurance or audit that required checks are completed.

What is not included
  • Excludes deficiencies limited to intra-operative treatment, surgical technique or post-operative care.
  • Excludes the separate assessment of surgical suitability or operative risk where no failure of pre-operative preparation or safety checking is identified.
  • Excludes generic staff training, auditing or equipment-maintenance concerns not directly tied to pre-operative preparation or safety checks.
  • Excludes failures in unrelated clinical preparation or diagnostic processes.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Brighton and Hove

    AI-generated summary

    Barry John TUCKER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The supplied text does not describe the circumstances of Barry John TUCKER’s death beyond recording that an inquest took place. Concerns included lack of pre-operative preparation and senior clinical input, absent enhanced-recovery support and information, inadequate hospital notes, flawed ambulance recall arrangements, and no coherent discharge-planning protocol for enhanced-recovery urology procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of pre-operative preparation

    Wider context from the report

    “(1) Mr. Tucker received no pre-op preparation. ”

    Source location

    Barry John TUCKER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.

    Verbatim wording from the response

    “Trust Response There is a care pathway document for Cystectomy patients which contains detailed discharge planning information, including prompts and checks which assist in documenting the key stages of the post-operative period and plan of care. That care pathway documentation was not used and the nursing and medical notes do not contain a great deal of detail of Mr Tucker’s post-operative progress. The Trust acknowledges the learning opportunity presented here and has implemented the action plan below.”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 5 · response
    Published 8 March 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use the cystectomy pathway documentation for all relevant surgical cases.

    Verbatim wording from the response

    “Recommendation: The Cystectomy Pathway patient documentation must be updated and used for all surgical cases no matter what ward to include the latest Cystectomy Enhanced Recovery Preparation Event and Recovery Pathway (CEPER) guidance and ensure clear to what patient information is provided and when (with sign off to state completed) and the discharge process/requirements;”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 5 · response
    Published 8 March 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Pre-operative preparation occurred through assessment by a nurse and consultant anaesthetist; the concern that no preparation occurred is disputed.

    Verbatim wording from the response

    “(1) Mr Tucker received no pre-op preparation”

    Source location

    2018-0018-Response-by-East-Sussex-Healthcare-NHS-Trust
    Page 3 · response
    Published 8 March 2018

    Open published response

  2. Manchester South

    AI-generated summary

    Michael Guy Hutchence · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Guy Hutchence broke his lower leg after slipping on an icy pavement and died in hospital on 28 January 2016. The report raised concerns about repeated ward moves, staffing and record-keeping, weight-based anticoagulant dosing and inconsistent weight recording, inadequate equipment for leg elevation, and delays to surgery after two operation kits were found to be non-sterile. The stated medical cause of death included bronchopneumonia, deep vein thrombosis and pulmonary embolus, and fractured tibia and fibula.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide usable sterile surgical kits

    Wider context from the report

    “7. The patient was taken to theatre for the operation and this could not be started as the “kit” for the operation was found to have a non-sterile status as the outer wrapping had been breached. The operation was delayed whilst another kit was obtained but this was also found to be defective. The operation was then aborted and put off for a further two days, during which time the patient was immobile and the risk of DVT and PE was inevitably increased. ”

    Source location

    Michael Guy Hutchence · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Proceeding with surgery when instrument-tray sterility was uncertain was unacceptable, requiring postponement until safe equipment was available.

    Verbatim wording from the response

    “Mr. Hutchence was scheduled for surgery on the trauma list for open reduction and internal fixation of fractured left tibia and fibula on 19th January 2016. It has not been possible to identify a particular cause for the breaches in the wrappings. Great care and attention is given to maintaining the integrity and sterility of the instrument tray wrappings. It is standard theatre practice that careful and thorough checking of every instrument tray wrapping is undertaken by the theatre practitioner prior to use. In this case, the routine checking identified the breaches and an appropriate action was taken to re-sterilise the instrument trays.”

    Source location

    2016-0228-Response-by-Stockport-NHS-Trust
    Page 3 · response
    Published 20 June 2016

    Open published response

  3. Manchester West

    AI-generated summary

    Kenneth Smalley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kenneth Smalley died after surgery to remove an infected aortic graft and repair an aortoduodenal fistula. During the surgery, an operating table moved uncontrollably and its emergency stop button did not work; later, bleeding from splenic lacerations required a splenectomy, and he deteriorated and died. Concerns included the safety, inspection, maintenance, positioning and checking of operating-table handsets, staff training and auditing, and the sharing of investigation findings between relevant organisations.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate staff training and auditing of pre-operative equipment checks

    Wider context from the report

    “(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”

    Source location

    Kenneth Smalley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Pre-operation checks failing to assess handset function, condition, seals and position

    Wider context from the report

    “(2) I have concerns with regard to the Wrightington, Wigan & Leigh NHS Foundation Trust in relation to i) The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27th March 2013. ii) Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. iii) The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacement of any damaged handsets. iv) The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. ”

    Source location

    Kenneth Smalley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement and disseminate a theatre-preparation procedure requiring operating-table checks before daily lists.

    Verbatim wording from the response

    “A Standard Operating Procedure for the preparation of Theatres prior to commencement of their daily list was ratified and disseminated in December 2013. Checks on the theatre tables must be performed as part of this SOP.”

    Source location

    2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
    Page 2 · response
    Published 19 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a daily checklist for critical equipment across all theatres, with sign-off and monthly auditing.

    Verbatim wording from the response

    “In addition we have developed a daily checklist for all critical equipment, in all theatres across the trust, which must be signed by the person performing the checks and audited on a monthly basis. The disciplinary procedure for non compliance is quite clear within the ‘Preparation of RAEI & Leigh Theatres SOP’. This policy is currently under review to include Wrightington Theatres.”

    Source location

    2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
    Page 2 · response
    Published 19 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the theatre-preparation procedure to extend it to Wrightington Theatres.

    Verbatim wording from the response

    “In addition we have developed a daily checklist for all critical equipment, in all theatres across the trust, which must be signed by the person performing the checks and audited on a monthly basis. The disciplinary procedure for non compliance is quite clear within the ‘Preparation of RAEI & Leigh Theatres SOP’. This policy is currently under review to include Wrightington Theatres.”

    Source location

    2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
    Page 2 · response
    Published 19 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a theatre-staff training system and matrix covering medical-device competence, compliance records, assessments and manufacturer guidance.

    Verbatim wording from the response

    “We have reviewed our staff training and now have a more robust system and matrix for training theatre staff maintaining records of training compliance. Building on the self assessment packs developed within the Trust for medical devices we have expanded our data base within theatres to cover all medical devices including medium and low risk items. Staff are assessed on competence and knowledge of devices and further training given as required. The medical device packs also include manufacturer’s user instructions and cleaning instructions.”

    Source location

    2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
    Page 3 · response
    Published 19 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and complete safety checks of all operating tables using Trust checklists based on manufacturer manuals.

    Verbatim wording from the response

    “The Trust has four different types of powered operating theatre tables in use and a total of twenty-four units. All theatre tables are maintained via external maintenance contracts. Since this incident, the Trust has developed its own checklist for each type of table based on the Manufacturers User Manuals. The Trusts own qualified Medical Engineering Technicians have undertaken thorough checks of all operating tables against these checklists to confirm their safety for use. The completed checklists will be attached to work orders as evidence of the findings should remedial actions be required.”

    Source location

    2013-0367-Response-by-Wrightington-Wigan-and-Leigh-NHS
    Page 2 · response
    Published 19 December 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026