Surgical Fires in the NHS

Steven Bonnar Excerpts

Thursday 16th December 2021 Westminster Hall

[Steven Bonnar (Coatbridge, Chryston and Bellshill) (SNP)]

It is a pleasure to serve under your chairmanship, Ms Rees. I congratulate the hon. Member for Strangford (Jim Shannon) on securing this debate on such an important matter. Surgical fires are rarely ever spoken about across the UK, but they are a more common occurrence than is perhaps first considered. When these tragic events do occur, they are very serious and can cause injury to both the patient and our healthcare professionals. Most surgical fires occur in, on or around a patient undergoing a medical or surgical procedure, with the most common injuries being on the head, face, neck and upper chest. The majority of the fires are caused either by a skin preparation solution not being given enough time to dry or because swabs soaked with the fluid were left in the operating field within an unsafe distance of an ignition source.

The sources can include drapes, towels, endotracheal tubes and swabs, and alcohol preparation solutions that have not been allowed to dry fully and as a consequence have pooled on or under a patient. Electrosurgical units, lasers and fibre-optic light sources are all well-described ignition sources for surgical fires, which have a devastating effect on patients physically and mentally. There are numerous personal accounts of patients who have been harmed due to those types of fires, and in nearly all cases they were wholly avoidable.

More recently, in one case a patient undergoing surgery for pancreatic cancer caught fire and suffered 40% burns and died a week later in hospital as a result of those injuries. It is even more vital that we have the protective measures in place to prevent these avoidable incidents from ever happening again.

Between 2010 and 2018 there were a total of 96 recorded surgical fires, as the hon. Member for Strangford pointed out. Those were declared by NHS England acute trusts and Wales health boards. The figures are similar in Scotland, from what I have been able to ascertain.

When doing my research for this debate, I spoke to a few of my constituents who work in the surgical field, based at the fantastic University Hospital Monklands, which cares for so many of my constituents. I am going to take this opportunity—I am sure Members would like to join me—to place on record my eternal gratitude to all those based at Monklands and across NHS Lanarkshire, as well as across all the nations of the UK, for the incredible work that they do all year round. We wish them all a safe and peaceful Christmastime. I spoke to my surgical constituents to get a real feeling of the impacts of such events, but also of any prolonged or psychological effects of such incidents on staff and patients. The information I received from my surgical constituents was illuminating and very concerning.

Recent research conducted by the National Reporting and Learning System found that from January 2012 to December 2018, 37 reported surgical fires were identified, in which 52% of patients suffered some degree of harm and 8% were recorded as receiving severe harm. Those statistics are of course alarming for us all. However, the data does not show the full scale of incidents that occurred from surgical fires because of the discrepancies between data held at national and local levels. That raises a question about the true number of incidents across the health boards. Is it greater than what has already been suggested? Is there even more cause for concern than we already believe? We need to explore that to get the answers to those questions.

We need a standardised approach to conduct a clear and effective reporting of incidents and decide on the correct steps to mitigate the risk of further surgical fires. It might surprise right hon. and hon. Members that the last time the term “surgical fires” was even uttered was almost seven years ago in 2015 by NHS England’s surgical services patient safety expert group—that is a mouthful—and yet nothing ever came of its work.

Three years later in May 2019, a short life working group for the prevention of surgical fires was established by a group of experts from healthcare organisations and bodies across the UK. The group aims to compile a series of recommendations and guidance that would make the case for surgical fires being ruled out and made the never event that the hon. Member for Strangford wishes to see. I join him in recommending to the Minister that it is crucial for theatre staff to have the training and for professional associations to explore the value of a national awareness campaign for healthcare professionals. We should mandate the inclusion of surgical fire prevention in the surgical and perioperative education and training syllabus.

NHS bodies should explore how to evolve the procurement process of sanitising products, to reduce surgical fire risk and encourage the procurement of proven surgical fire-safe technologies. I call upon all boards across the UK to explore the development of the standardised patient safety alerts system that aligns the processes and outputs of all bodies and teams. It is vital that such recommendations are implemented, especially given the expertise of those who have provided such information.

The prevention of surgical fires is an urgent and serious patient safety issue in all UK hospitals. It is also very costly, as research has found that nearly £14 million has been paid out in damages and legal costs on behalf of NHS organisations across the UK for such fires. It is essential that we understand when these incidents happen and fully examine whether we should successfully implement changes that prevent their future occurrence. It would be helpful if the NHS published an update on its progress on this matter, so that we can better understand the urgency of the action that is being taken.

Surgical fires are recognised as an international patient safety concern, so for all patients across the UK it is vital that we seek to mitigate their potential impacts as soon as possible. Sadly, it is not always possible to prevent patient safety incidents from happening, but preventive actions can and should be taken to prevent further harm to our patients in the near future.