SAFETY: Cambridge University Hospitals Foundation Trust failed to declare a never event incident, according to the Care Quality Commission.
HSJ has seen a letter sent by the CQC chief executive David Behan to NHS England which says a surgical incident, where the tip of a surgical glove around an inch in length was left inside a patient, should have been declared.
The trust did report the incident at Addenbrooke’s Hospital to the National Reporting and Learning System but did not declare it as a never event because it believed it did not meet the criteria.
The non-declaration was raised with the CQC earlier this year and it sought expert advice about the incident, which happened in January.
In a letter to Tom Easterling, director of the chair and chief executive office at NHS England, Mr Behan said: “We have concluded any identification of a retained foreign body after surgery should always be suspected of being a never event. As such, a suspicion of a never event is sufficient to require a national reporting of this as a never event.
“We have written to the medical director [of the trust] and informed the trust that this incident should have been reported as a never event.”
Following the incident the trust issued an alert and instructed theatre staff to carry out visual checks of surgical gloves after surgery.
A spokesman for the trust said: “We’re in an on-going discussion with the CQC about their interpretation of this incident.
“As we have already said, we told all the right people at the right time and have been open and transparent throughout. Our first priority is our patients and their safety.”
Information supplied to HSJ