An NHS trust was fined £180,000 before Christmas after a patient suffered severe burns from a warming mattress.
Mike Wilcock, 56, awoke from a minor operation with third degree burns to his hip and buttock as a result of the incident at Maidstone Hospital on 25 September 2012.
It is thought that a saline bag had been inadvertently placed on a sensor intended to monitor the mattress temperature, leading to an inaccurate reading that prompted the equipment to continue heating.
Mr Wilcock had been under anaesthetic and was therefore unaware of what was happening.
He required skin grafts, was unable to work for five months, and suffered a mild heart attack that was likely to have been attributed to the successive operations. Mr Wilcock was also forced to curtail his main hobby of sailing.
The Health & Safety Executive investigated the incident and prosecuted Maidstone and Tunbridge Wells NHS Trust, which runs Maidstone Hospital.
The HSE told Maidstone Crown Court that trust staff did not have sufficient information and training to ensure the heated mattress was used in accordance with the manufacturer’s instructions.
The court fined Maidstone and Tunbridge Wells NHS Trust a total of £180,000 and ordered it to pay a further £14,970 in costs after the trust admitted breaching Section 3(1) of the Health and Safety at Work etc Act 1974.
HSE Inspector Dawn Smith said: “Mr Wilcock suffered a serious debilitating injury that was entirely preventable had the Trust implemented a better system and procedures to ensure the warming mattress was used correctly.
“While the precise circumstances of what happened are somewhat unusual, it is entirely foreseeable that failing to ensure that staff know how to use a piece of equipment may have a negative outcome.
“The risk of injury from warming devices is well documented, and it also well known that anaesthetised patients require extra care and attention because they are not able to respond and react as they ordinarily would.”
Mr Wilcock said: “My case highlights the critical nature of suitable and adequate training for staff in how to use and maintain equipment.
“It also highlights that even with the most dedicated staff in the world things can go wrong, and when they do it is absolutely vital that a full and open investigation is carried out and that lessons are learned.”