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Much “soul-searching” has been done at Royal Cornwall Hospitals Trust recently, amid a cluster of never events which have prompted concerns over unresolved “cultural issues”.
The comments, made by RCHT CEO Kate Shields, describe the significance of the eight never events which have happened at the trust in the last six months.
Ms Shields and the RCHT board spent more than two years working to improve care at RCHT, and the trust was rewarded last April when it was taken out of special measures.
But the never events – including three in dermatology – indicate that some standards are beginning to slip, Ms Shields told HSJ.
The incidents appear to mainly be down to staff not following safety processes, but “communication problems” have also been a factor – Ms Shields said.
With the impact of covid-19 only believed to be – at most – one of several wider contributory factors to some staff not quelling old habits, Ms Shields believes the incidents are a “manifestation of the changes we have made not quite being embedded fully”.
She and the trust’s leadership team are now focused on hammering home those safety and quality improvements which contributed to less regulatory scrutiny.
DHSC under fire
Today HSJ revealed that the Department of Health and Social Care has been criticised by the national health ombudsman for the “maladministration” of a 2018 review into the death of a teenage girl under the care of one of England’s top specialist hospitals.
The Parliamentary and Health Service Ombudsman came to the conclusion after investigating a DHSC review into the 1996 death of 17-year-old Krista Ocloo which had been requested by her mother.
The young woman’s death was considered by the hospital’s complaints process, an independent panel review and an inquiry into the hospital’s paediatric cardiac services. They concluded the doctor involved was not responsible for Krista’s death – though the paediatric services inquiry criticised the hospital for poor communication. Read Matt Discombe’s full article here.