An ovary removed instead of an inflamed appendix: What happened?

On June 10, 2013 a 32-year-old pregnant woman was reported to have died after having an ovary removed instead of her inflamed appendix. As the infected appendix festered, she became septic and succumbed to multiple organ failure. This tragedy occurred in the UK in late 2011, but has just come to light.

How could this have happened?

Let me count the ways.

The surgery was performed by two trainee surgeons. Their level of experience was not stated.

The senior staff, called consultants in the UK, had gone home for the day.

The operation to remove the appendix was apparently done as an open procedure, not laparoscopic, which is acceptable if done correctly. The articles say that the surgeons had to take out the organ by feel and not under direct vision, which is not proper.

Although an ovary can be enlarged during pregnancy, under no circumstances does an ovary look or feel like an appendix. As in another case described below, inflammation can cause confusion at times, but not to this degree.

The woman was discharged a week after the initial surgery but returned with pain some 10 days after the removal of the wrong organ. During that time period, no one had checked the pathology report. The mistake was discovered by a doctor reviewing the patient’s records during the readmission.

An abscess was drained but the she died on the operating table during a futile attempt to at last remove the appendix.

Last week, the CEO of the hospital sent a written apology to the family promising to correct the dreaded “system errors.”

Too little, too late.

Yes, there were system errors.

But what about human errors?

Trainees were allowed to undertake a supposedly routine operation without supervision. However, as this case shows, an appendectomy during pregnancy can be very difficult. The uterus is in the way, and its increasing size may displace the appendix from its normal position. This type of surgery cannot be done by “feel” alone.

Commentary from UK physicians on Twitter suggests that all the facts of the case, such as what communications took place between the trainees and their supervisor, have not been made public. They also point out that it is not mandatory for a consultant to be present in the operating room for every case as is true of the resident-attending surgeon relationship in the US.

But I doubt that many US surgeons would allow residents to operate independently on a pregnant patient with appendicitis. At the very least, the attending would have been in the OR, if not scrubbed.

Did the trainees ask the consultant for help when they found themselves doing an appendectomy by feel?

The surgeons did not look at the pathology report, a major omission. But what about the pathologist? If a pathologist receives a specimen labeled “appendix,” and he finds only an ovary, wouldn’t the prudent pathologist pick up the phone and call the surgeon?

There is also “failure to rescue.” When the patient was readmitted, earlier recognition of sepsis and more timely intervention might have saved her life.

I am aware of a similar case in which an inflamed piece of fat was removed by two unsupervised trainees who mistook it for the inflamed appendix. On the following day, the pathologist called the attending surgeon to tell her that the appendix was not present in the specimen. The patient was promptly taken back to surgery. He wasn’t too happy, but he was alive.

The hospital’s investigation of this case should have taken a few days at most. If the media reports are true, disciplinary measures and remediation should have been promptly instituted. An apology should have been offered far sooner than it was.

“An extensive trust-wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again,” and “… to improve systems and patient safety,” said the hospital’s CEO.

As I have blogged before, system changes can be instituted, but can be defeated easily by carelessness, inattention and lapses of common sense by one or more individuals.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Marc

    All health systems have error rates but interestingly the US has one of the highest. I recall a study showing that surgical errors in the US are twice as high as in the UK’s NHS.

    • Suzi Q 38

      I believe it.

      • Skeptical Scalpel

        That might be true. I’d like to see a link to a study showing it though.

        • ninguem

          The USA and the UK and Europe don’t count INFANT MORTALITY the same way, I strongly doubt they count MEDICAL OR SURGICAL ERROR the same way.

          • Skeptical Scalpel

            Thanks for the information. I wasn’t aware of that.

          • ninguem

            Skeptical, if it came out of a female’s uterus, it has a pulse and breathes, it’s a live birth. It may not have a prayer of survival, and even to try to resuscitate it may be futile if not cruel. But it’s a live birth, and when it dies, it’s an infant mortality.

            Born before a certain gestational age, breathing or not, pulse or not, it’s a “miscarriage” in many countries, including UK and Europe.

            I’m not saying they’re letting neonates die that might live, not saying they are or are not. It could be we’re too aggressive in the USA. It may be perfectly reasonable not to do anything for an extreme premature neonate without a prayer of survival.

            Nevertheless, that very early preemie with measurable vitals, but not a prayer of survival, may be a “mortality” in the USA, but a “miscarriage” across the pond.

          • Skeptical Scalpel

            Thank you for clarifying that. Very interesting.

          • usvietnamvet

            Then maybe we need standardized reporting. It can’t be that difficult.

  • buzzkillerjsmith

    Your last paragraph is key. The idea that system errors killed this pt is laughable. Some physician or physicians dropped the ball here.

    • Skeptical Scalpel

      Thanks for commenting. A lot of people dropped the ball.

  • Suzi Q 38

    A friend of mine that said: If you don’t feel right after a surgery, chances are, something happened during the surgery….in this case, they took out the wrong organ someone’s mother died.

    How sad.

  • EmilyAnon

    In U.S. hospitals, is the patient informed ahead of time that they will be handed off to trainees without the surgeon of record in the room?
    And does it have to be noted in the operating report?

    • Skeptical Scalpel

      It is very different in the US. For billing purposes, the attending surgeon of record must verify in the operative note that she was present for all of the key components of a case.

      In all honesty, there are many instances where the attending surgeon may not be present at all. In that situation, the resident should put her name on the consent form.

      Does this happen the way it’s supposed to all the time? Probably not.

  • David Gelber MD

    Blaming the system for individual incompetence seems to have become the new game in town. Surgery has always been a specialty where individual compulsiveness is a prerequisite. I don;t know how much sleep I have lost thinking about and mulling over and worrying about a surgical case that wasn’t going right. In the end i always do whatever I need to do to be sure everything has been done to treat the patient and any potential complications,
    And, on a side note, I don;t know how any “surgeon” can mistake an ovary for the appendix, inflamed,pregnant or not.

    • Skeptical Scalpel

      David, good points. I agree with you about the compulsiveness and worry. Also, it’s hard to understand mistaking the ovary for the appendix.

      Re your other comment. There were enough details to judge whether the surgery could have been avoided.

  • David Gelber MD

    One other comment. I wonder if it was really necessary to operate on the patient to remove the appendix. Once She ahd developed an abscess and it had been drained, trying to remove the appendix at that point may cause more trouble. If the patient had been stabilized by draining the abscess, than surgery at that time would be difficult and most likely would end up making the patient sicker.

  • Skeptical Scalpel

    An appendectomy on a pregnant patient is not routine.There weren’t enough details in the article to know exactly why the consultant surgeon wasn’t there. Thanks for the link.

  • usvietnamvet

    I was lucky that the surgeon who took out my appendix was well experienced and didn’t decide there was nothing wrong even though the appendix was in the wrong place. I had suffered from chronic appendicitis for years before 2 very good doctors (one a GP and one a surgeon at the GJ VAMC) finally found what was wrong with me. It could have so easily went the other way. My appendix was 3 times it’s normal size with much scarring.

  • lissmth

    Central planning is not always so good with that efficiency and excellence thing.

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