Recurring concern

Unreliable use of the WHO Surgical Safety Checklist

First to latest report 18 May 2015 — 16 May 2016

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
2

What this concern includes

Includes failures of the WHO Surgical Safety Checklist process, including failure to use or complete the checklist and failure to communicate, verify or document procedure-specific safety information through it across surgical, radiological and comparable interventions.

What is not included
  • Excludes generic communication, documentation or procedural-safety deficiencies where the WHO Surgical Safety Checklist is not the identified control.
  • Excludes failures of other checklists or protocols unless the report explicitly links them to the WHO Surgical Safety Checklist process.
  • Excludes clinical errors occurring after the checklist was reliably completed when no checklist deficiency contributed to the error.
  • Excludes the underlying risks of a procedure or intervention when no failure of the WHO Surgical Safety Checklist process is identified.

Reports and published responses 2 reports

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

  1. Surrey

    AI-generated summary

    Mr Critall · 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

    Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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 use a WHO checklist for radiological interventions

    Wider context from the report

    “7. Best practice measures had not been instituted in the radiology department to safeguard patients undergoing radiologically interventions. This included completion of an appropriate consent detailing complications, radiological indications for insertion of a chest drain independent of the respiratory consultant, a WHO checklist, no observations (BP, HR, temp etc) before or after the chest drain procedure on a backround of poor communication with the ward staff as to what plan was in place other than an outdated protocol for management of chest drains on the ward which did not address action was to be taken if complications arose. ”

    Source location

    Mr Critall · 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

    Audit and reinforce complete consent documentation, including procedural risks, benefits, complications and radiological indication for chest-drain insertion.

    Verbatim wording from the response

    “In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 6 · response
    Published 16 May 2016

    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

    The radiology department already used the WHO procedural checklist, required comprehensive consent and audited compliance.

    Verbatim wording from the response

    “In 2014 the WHO check list for procedures was introduced into the radiology department and is now every day practice and all consultants were aware of the requirement to undertake a comprehensive consent detailing risks and benefits of the procedure. Following the incident the consultant body were reminded of the necessity to ensure that documentation is complete detailing possible complications on each consent form. This process is subject to audit which confirms compliance with this standard.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 6 · response
    Published 16 May 2016

    Open published response

  2. Gloucestershire

    AI-generated summary

    Diana Ruth Hughes · 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

    Diana Ruth Hughes, aged 66, underwent cholecystectomy that was converted to open surgery and later developed widespread bowel infection and infarction. She deteriorated rapidly and died in the recovery room on 9 January 2014. The substantive concern was how specific instructions for a surgical procedure are communicated to other medical personnel via the WHO/Surgical checklist.

    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

    Unclear communication of specific surgical procedure instructions via the WHO / Surgical checklist

    Wider context from the report

    “(1) How specific instructions for a surgical procedure are communicated to other medical personnel via the WHO / Surgical checklist. ”

    Source location

    Diana Ruth Hughes · Prevention of Future Deaths report
    Page 1 · 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

    Amend the WHO/Surgical checklist to direct staff to verify that special post-operative instructions are written on the operation note.

    Verbatim wording from the response

    “1. Consideration is being given to amending the WHO/Surgical checklist document to include an additional instruction to direct staff at the end of the procedure to check whether ‘special instructions’ for post-operative care have been physically written on the operation note.”

    Source location

    2015-0195-Response-by-Gloucestershire-Hospitals-NHS-Trust
    Page 1 · response
    Published 18 May 2015

    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