Swab mistake at L&D contributed to lorry driver's death, inquest hears
A swab that was mistakenly left in a patient at Luton & Dunstable Hospital contributed to his death 13 years later, an inquest has heard.
Shortly before his death in 2014, scans revealed that Frank Hibbard had a swab around his pelvic region– which had been there since a prostate operation at the L&D 13 years earlier.
By that time a mass attached to the swab had calcified, grown around veins and increased to the size of a melon, pressing on his rectum and bowel.
Mr Hibbard, 69, from Luton, died before an operation to remove the mass could be carried out.
An inquest held on Monday heard that the only two possible causes of the angiosarcoma cancer which killed the lorry driver was the presence of the swab and radiotherapy the 69-year-old received after his surgery in 2001.
Professor Robert Grimer, a consultant orthopaedic surgeon, told the inquest that on average angiosarcomas caused by radiotherapy take 10-12 years to develop, while those caused by foreign bodies often take 20 years.
Adding that the statistics could not be fully trusted as cases are rare, Prof Grimer said: “Either in isolation could cause angiosarcoma, the presence of the two factors contributed together.”
Two years after his prostate operation Mr Hibbard had a CT scan at the L&D, but the swab in his pelvis was missed by doctors.
Referring to the scans Prof Grimer said: “To a surgeon it would say it should not be there but to a radiologist they may not know.
“It very clearly shows down in the pelvis there are some fine lines which is the retained swab.”
The inquest heard that after the swab was discovered by doctors in March 2014, they concluded it was ‘unlikely’ that the angiosarcoma was caused by radiotherapy.
However a report by Prof Grimer placed the two possible causes on equal footing.
Jack Howell, representing the L&D, asked Prof Grimer if he thought Mr Hibbard’s angiosarcoma was more likely caused by radiotherapy or by the swab.
The surgeon told the inquest: “The conclusion I have reached is that two together had an effect.
“(Swab retention) is mortifying, it is something that just does not happen.
“We do not know how many retained swabs there are.”
Senior coroner Tom Osborne recorded a narrative verdict which listed ‘complications of treatment’ as the third cause of Mr Hibbard’s death.
Mr Osborne said: “It is a very tragic case and my heart foes out to the family for losing Frank in these circumstances.”
Mr Hibbard’s widow Christine is taking legal action against the L&D for its errors in 2001 and 2003.
An L&D spokesman said: “We extend our condolences to Mr Hibbard’s family and apologise sincerely for the error that took place in 2001 when a swab was unintentionally left in situ after a surgical procedure.”
He added: “This is clearly something that should never have happened.
“We would like to reassure Mr Hibbard’s family that, since the time of this incident, we were one of the first hospitals in the UK to introduce the World Health Organisation’s Safe Surgery Checklist to minimise the possibility of this happening again.”