Cornwall's main hospital trust records eight 'never events' in just six months
It comes after 13 months without any
Cornwall’s main hospital trust has recorded a cluster of “never events” in the last six months including a wire left inside a heart patient.
Royal Cornwall Hospital Trust (RCHT) recorded the “never events” since April – a never event is classed as a serious incident which is entirely preventable.
The Trust Board received a report in October providing an update on never events and at that time there had been five recorded.
When the board met again earlier this month it was noted that another three incidents had since been recorded.
The five earlier incidents were:
February 2020 (reported May 2020) – swab retained during breast surgery at St Michael’s Hospital
May 2020 (reported May 2020) – wrong site surgery in dermatology at West Cornwall Hospital
June 2020 (reported July 2020) – wrong site surgery in dermatology at RCHT
May 2020 (reported July 2020) – partial retained guide wire in cardiac catheter
September 2020 (reported Sept 2020) – incorrect intraocular lens inserted, opthamology Newlyn Theatres
In the case of the retained swab an investigation found that the swab count, as part of a sign-out process, had failed leading to an incorrect count.
The report states: “Given the time which had elapsed between surgery and identification of the retained swab it has not been possible to identify exactly how this error occurred.”
In the dermatology cases the report says that “significant errors” in the implementation of the safety checklist had been identified as the root cause or contributory factors.
It adds that there had been five serious incidents and one previous never event reported in dermatology at RCHT between 2011 and 2020 and that there were common themes in those.
These included the site of the lesion to be removed not being marked and confirmed with the patient; and the consent form not being specific to the lesion for removal, particularly when more than one lesion was to be removed.
The report states that the cardiac incident found that a 39cm section of guide wire had broken off from a 190cm wire and was not detected during its use in a procedure.
It notes: “It is unusual for these wires to fracture, although it has been reported in other sites. On occasions when the wires do break, this is usually associated with a more complex procedure requiring difficult manipulation. This was not the case here.”
And it adds: “In the cardiology incident the root cause is considered to be the failure to recognise that the angiography wire was not intact on removal.”
As a result a recommendation was made that all wires shoudl be checked at the end of a case and a record of all wires used be completed. The action has already been implemented.
In its reports the RCHT board noted that: “An internal quality summit is to take place chaired by the Chief Executive with full executive and relevant care group representation to explore these issues in more depth and develop a comprehensive improvement plan.”
In a statement RCHT said: “We are very disappointed that we have had never events after 13 months of not having one.
“While a Never Event is exactly that and should never happen, unfortunately human error can occur. Through our teams embedding ways of working together, identifying when things go wrong and putting in place improvements, we are striving to become the safest hospital in the UK. This is a core part of us providing the best care to our people in Cornwall and Isles of Scilly.
“Whilst none of the Never Events resulted in long term harm to patients, it is absolutely right that we are open and transparent about them, particularly where they could suggest a need for national changes in practice.
“We realise that none of us are infallible but feel proud and encouraged that our staff are much more confident in reporting any incidents, so we can rigorously review what went wrong and, most importantly, learn and prevent them happening again and through that provide safe and effective care for patients.”
Royal Cornwall Hospitals Trust