Two 'never events' at Cornwall's main hospital, safety inspection confirms
The Care Quality Commission praised recent improvements at the trust which runs Treliske, but found more are needed
Last updated 20th Aug 2021
Inspectors have praised improvements made in surgical care services at three hospitals run by the Royal Cornwall Hospitals NHS Trust, but found more are needed.
The Care Quality Commission (CQC) carried out focused inspections at the Royal Cornwall Hospital, St Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance in June, to look at how safe and well-led the surgical care service was.
These were carried out to follow up on concerns identified during a previous inspection last December, which led to the trust being served a warning notice.
At that time, the trust had reported seven never events across the three hospitals which took place between February and October 2020.
These are defined as incidents that have the potential to cause serious harm or death that should not happen if healthcare providers follow guidance on how to prevent them.
During the recent inspection, CQC found that the trust had made a number of improvements and met all the requirements of the warning notice. However, it had reported a further two further never events, both at Royal Cornwall Hospital.
As this was a focused inspection, the overall rating for surgical care was not re-rated and remains requires improvement for Royal Cornwall Hospital and West Cornwall Hospital, and good for St Michael’s Hospital.
The overall rating for Royal Cornwall Hospitals NHS Trust and for Royal Cornwall Hospital is requires improvement. St Michael’s Hospital and West Cornwall Hospital are rated good overall.
Cath Campbell, CQC’s head of hospital inspection, said: "After inspecting the surgical care services at Royal Cornwall Hospitals NHS Trust in December, we served the trust with a warning notice as we had a number of concerns about how leaders at the trust were assuring themselves that people were receiving the best care possible. However, I am pleased to report that significant improvements have been made since then, which will have a positive impact on people who need to use these services.
“Since our last inspection in December, the trust has reported two further never events which took place at Royal Cornwall Hospital. In February there was an incidence of wrong site surgery* carried out in the interventional radiology department, which is where minimally invasive, image-guided medical treatments are carried out. Then in June, a patient received an overdose of insulin.
“Both these situations should not have occurred, and it is imperative that the trust learns from them and ensures that all staff are told and made aware of how to avoid a similar situation in the future. In this case, each incident is being fully investigated to understand what went wrong and lessons learned shared with staff across all sites.
“Although there are still some further improvements to be made, the trust has done a good job in addressing our concerns and making and embedding improvements since our last visit. Consequently, nearly all staff we spoke with knew about a recent never event, and all staff knew about those which related to their own role or specialty.
"This was a noticeable improvement since our last inspection when staff could not demonstrate that they were aware of any information about never events or any learning from these. This has been done despite the additional pressures resulting from the COVID-19 pandemic, so the leadership team has done exceptionally well".
*An incident of wrong surgery means that surgery has been performed on the wrong body part, the right body part but the wrong side of the body or on the right body part but on the wrong patient.
What did the inspection find?
The RCHT was served with a warning notice in December after issues were raised around governance and patient safety, how long it took the trust to respond to never events and staff training and audits.
At this inspection the trust was found to have made significant improvements:
• Leaders understood and managed priorities and issues the service faced. Governance structures and communication within them had improved and there was more joined up working between Royal Cornwall Hospital, St Michael’s Hospital and West Cornwall Hospital. Changes and learning supported patient safety across the trust.
• Staff felt respected, supported and valued. The service had an open culture where staff could raise concerns without fear. Staff at all levels were clear about their roles and understood what they were accountable for, and to whom. They recognised change was needed as a result of the never events, to ensure patient safety.
• Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and, in most cases, kept good records. They also managed medicines well.
• Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together across all hospital sites for the benefit of patients and had access to good information.
• The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. Further improvements had been implemented to ensure actions to mitigate further risks of never events do not increase risk in the short term.
• Compliance with the World Health Organisation (WHO) Surgical Safety Checklist had improved, and further improvements were in progress.
• Managers responded to incidents and shared information in a timely way. The programme of audits of the WHO Surgical Safety Checklist had been reviewed with a targeted audit schedule. A safe surgery group had been implemented to review audit findings and share learning with the wider team.
• Compliance with training had improved with over 80% of staff having completed the WHO checklist and Human Factor training. There was an ongoing programme to ensure the rest of the workforce completed the training.
However, the inspection found improvements were needed in the following areas:
• Documentation relating to people’s surgery was not always completed fully and consistently.
• Although the trust provided assurance that the WHO checklists were being updated to include a patient safety alert, the updated documents had not been circulated yet.
• Relevant information about allergies was not written on the board in theatres potentially putting people at risk if their allergies weren’t known
The Royal Cornwall Hospitals' NHS Trust says it welcomes the findings of the new inspection.
Deputy Chief Executive and Director of Nursing, Midwifery and Allied Health Professions at RCHT, Kim O’Keeffe said: "We welcome the Care Quality Commission’s report and are really pleased it recognises the improvements we have made and that assessors were satisfied we have met the requirements of the warning notice given to us last December.
“It has been particularly challenging, whilst responding to the Pandemic, to put in place the changes we are committed to, and absolutely needed to make. Our teams have really pulled together, adapting and sharing new ways of learning, to make sure they are putting patient safety first.
“Our focus on human factors training – heightening people’s awareness of the points where human errors are likely occur in a process and how to overcome them – is making a big difference, as is the more open culture where colleagues feel more confident to speak up.
"Quality and safety of care remains our top priority and we recognise we still have more to do. We continue to scrutinise any incident or Never Event to ensure we learn everything we can and put in place measures to avoid the same thing happening again in the future".
More information can be found in the Care Quality Commission's full report.