An independent report into how the wrong kidney was removed from a child at Our Lady's Children's Hospital Crumlin earlier this year has concluded that there were ten contributory factors to the error.
The review by Great Ormond Street Hospital, London, says the child had a poorly functioning right kidney, which was incorrectly listed by a consultant general surgeon for a left-sided nephrectomy.
Consent was obtained from the parents for the removal of the left kidney and the procedure was carried out by a specialist registrar in paediatric surgery who had not seen the patient previously.
Before the operation took place however, the parents had raised concerns on a number of occasions with nursing staff about the side planned for the surgery.
The parents of the child also raised concerns on a number of occasions with nursing staff about the side planned for the surgery before the operation took place.
The report has also blamed an incorrect imaging report that was six years old, the fact that no fail-safe system to ensure a multi-disciplinary meeting was held when a major organ was to be removed, as well as the long hours and workload of senior doctors.
The hospital says it takes full responsibility for the tragic error and has apologised to the family, which has chosen to continue to have their child cared for at the hospital.
Other failures identified were the regular admission of patients outside of normal working hours, radiology reports not being sent to theatre and formal consent being taken by surgeons who are not competent to perform the procedure.
The family has reiterated their appeal for their privacy to be respected.
Our Lady's Children's Hospital has introduced a 'correct site surgery' policy and says it accepts all the recommendations.
