Trust declares 'never event' after clinician operates on wrong patient

University Hospitals of Leicester Trust has declared a “never event” after a man underwent surgery intended for another patient with the same surname.

The trust has ordered an urgent risk assessment of activity levels against patient safety after warning staff they will be “held to account” if safety procedures are not followed.

An email, sent to staff and seen by HSJ, stated: “All invasive procedures must have a robust safety checking process in line with UHL policy that is followed and you need to assure yourselves that this is happening within your own practice and/or your services.

“Please check your administrative and clinical processes to assure yourselves that this could not happen in your service.

“Any staff not following the trust’s procedures will be held appropriately to account.”

The trust’s board heard this week the first man, known as Patient A, was added to the waiting list for the excision of a right upper back lesion after attending a dermatology clinic.

However, the appointment for the surgical procedure was sent to another man with the same surname, although no other personal details were similar.

The second man, known as Patient B, had gone to see his GP six months earlier about a mole in the same area but did not require a specialist referral.

He underwent the procedure intended for Patient A in August because proper safety checks do not appear to have been carried out.

A meeting of the trust board this week was given details of the never event, the fourth to be declared by Leicester this year.

A report stated: “On initial findings, it appears that inadequate safety checks were performed at the time of the procedure by the operating clinician as the consent form, biopsy form and last clinic outcome slip all belonged to Patient A.”

“Robust” team briefings including medics and outpatient staff in dermatology have been introduced alongside spot audits on processes and procedures in dermatology and an external review of dermatology administrative processes will also be undertaken.

A spokesman for the trust said: “The initial error was identified by the clinic coordinator the following day after the procedure when they tried to book a follow up appointment for the patient.

“It was noted that there was no previous appointment for this patient on the system which would indicate the patient had not been referred or had an initial appointment to plan for the procedure.”

The never event is the latest setback at the trust which has been told by NHS Improvement its “sustained poor performance” in A&E must improve to protect its reputation.

• Article updated at 1pm on 6 October to include the trust’s statement.