The chief inspector of hospitals has warned four out of five NHS Trusts in England need to improve in patient safety.

It comes as ITV Tonight reveals the extent of serious medical mistakes.

Lisa Brewer, 45, from Essex discovered a lump in her breast just over a year ago.

She had a number of tests including a mammogram, which she was told was ‘encouraging’.

Doctors also took biopsies tissue samples from both breasts, to rule out cancer.

Two weeks later she received the results from her doctor.

I knew something was wrong, because I could just tell by her face. And she said 'It’s not the news we were expecting but I am afraid you’ve got grade 2 cancer of the breast.' I remember thinking, I got ready today looking in the mirror putting my makeup on and I was fine and now I have got cancer.”

Lisa Brewer

Facing the possibility of having both breasts removed the mum-of-five had life saving surgery.

Lymph nodes and other parts of her breasts were removed.

Permanent scarring

She was left with permanent scarring.

Weeks later the hospital revealed it had made a massive blunder.

Lisa was told: “There’s been some kind of mix-up.”

It’s weird I didn’t feel relieved, because you can’t just shut them emotions off like that straight away. Having to tell people that I’d previously I had told I had cancer. And tell them I don’t have it, I felt like a fraud in some way.”

Lisa Brewer

Told she did not have cancer when she did

It meant another woman was told she did not have cancer when she did.

ITV Tonight contacted her, but she did not want to be identified: “I had to go through an additional, unnecessary, operation, but my breast cancer treatment was fortunately not delayed. I am now concentrating on my recovery.”

Fiona Strachan, an expert medical negligence lawyer at Irwin Mitchell, representing Lisa, said:

Lisa has been incredibly courageous in coming forward to speak about what has been a traumatic time in her life, in the hopes that no one else suffers a similar ordeal. Not only has Lisa undergone treatment based on this incorrect diagnosis, but she has struggled to come to terms with the emotional impact of such a severe mistake. We are currently investigating Lisa’s case and we hope that lessons can be learned to ensure this horrendous error cannot happen again.”

Fiona Strachan

The NHS deals with over 1 million patients every 36 hours so mistakes like Lisa’s are incredibly rare.

Today the health watchdog the Care Quality Commission's (CQC) chief inspector of hospitals, Prof Sir Mike Richards criticised a "failure to learn" in NHS England when things go wrong.

But ITV Tonight can reveal there is one type of serious clinical medical case that is now the highest in four years - these are called ‘never-events’.

There is now one of these ‘wholly preventable’ medical mistakes happening every day in the NHS in England and Wales (465 in 2015/16).

They can be the wrong part of the body operated on.

ITV Tonight spoke to one person who did not wanted be identified who had a kidney removed by mistake.

Sometimes it can be where things have been left inside the patient after surgery.

“Gauze, it was about twelve inches in length,” explained Vince Hibbard.

Frank Hibbard Credit: ITV / Tonight

His father, Frank, went in for a prostate operation in 2001 and even though the operation went well, the surgical team left the large lump of gauze inside him by mistake.

It was left inside him for 13 years.

The swab recovered from Frank after 13 years Credit: ITV / Tonight

It was within his groin and you imagine that in your groin pressing on all your nerves, your bones, your joints. I watched my dad suffer for years. I watched him go from being very active, he was very fit. I saw him deteriorate to the point that he died an awful death.”

Vince Hibbard

Luton and Dunstable University Hospital carried out the operation and also missed the swab in a CT scan in 2003.

Frank Hibbard died in 2014, just a few months after the gauze was found.

It had calcified into a mass the size of a small melon.

The coroner said it had ‘materially contributed’ to Frank developing a type of cancer ‘which ultimately led to his death’.

The Hibbard’s lawyer was Renu Daly, from Hudgell Solicitors:

Sadly Frank’s wife Christine died very recently in January. She felt she never actually received a full apology from the trust and that affected her right up until her death.”

Renu Daly, Hudgell Solicitors

The Trust has apologised to the family, and says safe surgery checklists are followed to ‘minimise the possibility of this happening again’.

Andrew Miles from the Royal College of Surgeons says the pressures in the profession “may be greater just at this moment, than it has been in the past”.

But there have always been pressures and it’s up to us to cope with it. What we mustn’t do is sacrifice patients' safety in order to get numbers through.”

Andrew Miles, Royal College of Surgeons

In the surgical and medical profession a ‘second victim’ is also referred to and this is the person who made the mistake.

This was a long time ago, about 25 years ago when I was a registrar and the procedures were different, they did not have the same checks in the system.”

Andrew Miles, Royal College of Surgeons

Operated on the wrong leg

He said he almost operated on the wrong leg during a minor procedure, but the theatre nurse stopped him.

We found that the correct leg that I had marked only an hour before, the ink had transferred from one leg to another. That is such a frightening event that even now talking about it just brings me out in a cold sweat.”

Andrew Miles, Royal College of Surgeons

The NHS says it takes mistakes very seriously and is now turning to some unexpected quarters for advice - like the airline industry.


Aviation experts say it has more of a ‘no-blame’ culture when it comes to people being open and honest about reporting mistakes and it promotes the legal ‘Duty of Candour’ among professionals.

The former Chief Inspector of the Air Accidents Investigations Branch Keith Conradi, will head up the Healthcare Safety Investigations Branch when it is launched next month.

In response to Medical Blunders Revealed the Health Secretary Jeremy Hunt said:

We want the NHS to offer the safest and best care anywhere in the world - which means becoming an organisation that consistently learns from its mistakes and makes improvements in the interests of patients, and we have a big programme of reform underway to help achieve that goal. From April, all NHS Trusts will be required to publish how many deaths they might have been able to avoid, along with the lessons that they have learned to improve care. The Healthcare Safety Investigation Branch will help the NHS learn from mistakes in the same way that the airline industry does and improve the quality of investigations across the NHS."

Jeremy Hunt, Health Secretary

NHS: Medical Blunders Revealed - Tonight is on ITV this evening at 7.30pm

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