An acute trust has commissioned an external review of its operating theatres following a string of never events, all of which caused harm to patients.

Dartford and Gravesham Trust had only had one never event between 2013 and October 2016 but then reported a cluster of four in 11 months, all of which involved surgery and all of which it says resulted in patients coming to harm.

These were:

  • A retained vaginal swab, in October 2016;
  • An incorrect knee implant, which was later removed in a second operation following a fall, also in October 2016;
  • Removal of ovaries – which were meant to be preserved – in a hysterectomy operation, June 2017;
  • Use of an incorrect hip implant, which needed corrective surgery, in August 2017.

In response the trust has commissioned an external review, to be carried out by a former director of nursing, because of “common findings and actions” among the four never events.

However, it will only review the trust’s orthopaedic theatres – where two of the four never events took place. The theatres which saw the other two will not be within the scope of the review.

It has also used more simulation training, revised its policy around the World Health Organisation surgical checklist and asked all directorates to consider their own risks of never events and include those on their risk registers.

It has refused to give any details of the review’s timescale or terms of reference.