Part of a wire was found in a patient at the Royal Stoke University Hospital, health bosses heard at a meeting.
But University Hospitals of North Midlands (UHNM) NHS Trust’s board was told the patient was “fine” following the incident, which was detailed in a performance report for April.
The report said: “Patient required insertion of a temporary haemodialysis catheter. During this procedure part of the guide wire was unintentionally retained in the patient.
“The inner core of the guide wire was retrieved when the procedure was abandoned and was noted to be in a non-kinked state. There was no suspicion of any retention of the guide wire, or elements of it at the time of removal.
“The line was inspected on removal. On visual inspection it appeared normal and therefore no concerns were raised at the time.
“Due to the patient having some pain/discomfort a CT scan was arranged which highlighted the retained piece of guide wire.”
Liz Rix, the trust’s outgoing Chief Nurse, told Wednesday’s meeting: “It was removed and all was fine. We do flag it up to manufacturers.”
Medical director John Oxtoby added: “It’s unfortunate, it’s another different variation on a theme. The guide wire has shirred off and part of the wire was retained in the patient.”
There have been two other “never events” reported at the trust in 2019.
A patient found an “alleged retained swab” after being discharged from hospital following a procedure.
The other incident involved a unit of incorrect blood being used in a transfusion following a “massive haemorrhage”. But the patient made a full recovery and was later discharged, a report said.
In summer 2018 a guide wire was left in a critically ill patient’s body on the paediatric intensive care unit (PICU). An investigation took place following the incident and UHNM took a number of actions, including removing central venous catheter (CVC) sets containing two guide wires from the unit.