A window through which an operation was viewed by visitors and other patients at Epsom Hospital was fitted with a blind which was left open for a fortnight, it has been revealed.
In January, the Epsom Guardian told how a horrified Claire Walsh, witnessed an operation taking place in a building opposite the Wells Wing of the hospital as the blind of the room had been left open.
Miss Walsh said she, other visitors and a patient saw surgeons operating on a patient and her concerns were dismissed by a nurse who said "it happens all the time".
After the incident, the hospital revealed that another member of staff had overheard Miss Walsh’s concerns and the window in question was quickly covered with foil and then frosted over.
It launched a "thorough and urgent investigation" into what happened, some of the findings of which have now been released to this newspaper, six months later.
A spokeswoman said the window had a reflective coating and the blind, which acted as reinforcement, was not closed properly after the window was cleaned.
And that because of the "particular time of day and year, the inside of the theatre could be seen".
Although the blind had been left open for two weeks, the hospital said it does not believe any other operations were seen.
But not only was additional frosting added to the window in question, another 15 windows at the hospital have also been frosted over since February - the majority, "to enhance our patients' privacy and dignity".
In a statement, Epsom and St Helier Hospitals Trust said: "We are absolutely committed to protecting the privacy and dignity of all of our patients.
"In January, it was brought to our attention that a secure blind in a window to one of our operating theatres, which is usually closed and locked between two panes of double glazing, was not closed properly after the window was cleaned.
"As such, part of one of our operating theatres was visible to a small number of other patients.
"We have identified a number of contributory factors to the incident, undertaken some key actions and made sure we have learnt lessons.
"The blind was not closed following a deep clean of the area and staff on duty failed to check and report that it had remained open for a maximum period of two weeks.
"As such, we have undertaken further training with all those involved.
"The reflective glaze on this particular window would ordinarily screen the theatre from view, with the blind acting as reinforcement.
"However, at this particular time of day and year, the inside of the theatre could be seen.
"As a result, we have fully frosted the window and undertaken a review of all other windows across our sites."
When asked why frosted windows were not installed to begin with, the spokeswoman said the windows were fitted "some years ago" and the project team responsible no longer worked for the Trust.
Asked whether the Trust acknowledged that a reflective coating on windows with blinds is not a cast-iron guarantee of privacy when the sun is not reflecting off such windows and if the blinds are left open, the spokeswoman said: "In this case, we accept our usual precautions did not go far enough in protecting this patient's dignity."
Speaking to the Epsom Guardian at the end of May, Dr Ruth Charlton, joint medical director of the Trust, said the incident was graded as worthy of a Level 4 investigation, on a scale on which Level 1 is the least serious and Level 5 the most serious.
Dr Charlton said Level 4 warrants "a comprehensive investigation with a root-cause analysis."
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