The Royal College of Surgeons has been asked to review a trust’s specialist service following never events and concerns over staff culture.

Burton Hospitals Foundation Trust has asked the RCS to carry out a review into its trauma and orthopaedics department, following three never events and a serious incident in 2017.

The RCS review comes after the trust sought an independent review from the Healthcare Safety Investigation Branch into a never event related to prosthetics at its trauma and orthopaedic unit.

Governing body papers published by East Staffordshire Clinical Commissioning Group last month said HSIB visited the trust in November.

A consultant from University Hospitals of North Midlands Trust has also reviewed one orthopaedic never event that resulted in a patient death.

The CCG also raised concerns about the culture at Burton’s orthopaedic and ophthalmology departments.

The papers said: “The last report described ongoing issues in both orthopaedics and ophthalmology and described an apparent lack of escalation or challenge made by peer consultant colleagues, clinical leads, senior nursing staff etc when things have gone wrong and patient harm has occurred…

“Within two specialities, serious errors have occurred with no escalation through trust governance processes, thus resulting in the executives not being aware until external reviews are undertaken, concerns escalated by commissioners or cases are presented to their internal [serious incident] review meeting.”

Tosca Fairchild, head of governance for Burton Hospitals FT said: ”Trust executives have been fully briefed on issues in orthopaedics and ophthalmology, and are committed to learning from the RCS review when it takes place later this month. All due processes have been followed throughout, and it was the Trust Board and executives which sought reviews from the Healthcare Safety Investigation Branch and the RCS.

”It is therefore incorrect to suggest that executives were not aware of the issues in a timely manner.” 

Last year, the trust commissioned an independent review into its ophthalmology service following four never events in 2016-17. HSJ understands this review is now complete.

The trust is set to merge with neighbouring Derby Teaching Hospitals FT this month after the Competition and Markets Authority approved it in March. The new trust will be called University Hospitals of Derby and Burton FT.

This story was updated on 11 April at 16:18 after HSJ recieved a comment from Burton Hospitals FT.