AN INVESTIGATION is underway into a suspected never event at a county hospital in which a patient died.
Bosses at Worcestershire Acute Hospitals NHS Trust say they cannot release detailed information about the event while the investigation is ongoing but it has been revealed it involved giving the wrong gas to the patient during a procedure at Worcestershire Royal Hospital.
It is not known yet if the error directly resulted in the patient’s death and information has been passed to the Worcestershire Coroner and organisations including Redditch and Bromsgrove Clinical Commissioning Group.
Mark Wake, the Trust’s chief medical officer, said they were reflecting on all the circumstances and evidence available but the results of any investigation into serious events were shared with patients, families and carers as well as externally.
“In the rare and regrettable instances where they do occur, an investigation is immediately undertaken to find the root causes, develop solutions for and then implementing them where the incident occurred and more widely if required. This helps to reduce the likelihood of a similar incident re-occurring.”
The Department of Health has listed 25 errors, which are deemed largely preventable and classed as so serious they should never happen or never events.
If it is confirmed as a never event it would be the Trust’s second in four months after a patient undergoing cataract surgery had the wrong lens inserted. The mistake was quickly rectified and no harm was caused to the patient who was informed of the error.
An investigation revealed it was a result of numerous factors including the order patients were due to be operated on changing as a result of someone arriving late, the electronic records system being down and the surgeon being under time pressure and personal stress. Changes have been made to ensure there is no repeat including reducing the number of cases on one surgery list from eight to seven.
NHS England say they will soon be publishing details of all never events listed by hospital trust, every three months, so they can be compared.
During the last financial year there were 299 such events nationally, which include patients being fitted with the wrong implant or the wrong part of the body or person being operated on.
Dr Mike Durkin, director of patient safety at NHS England, said the move was not about allowing people to lay blame inappropriately but to understand and learn more from safety problems which the NHS, like all healthcare systems, faced.
“Every single never event is one too many,” he added.
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