Herts trust reviews neonatal never event

The case in May - which has taken the trust to its limit of one case in the first quarter of the financial year - has led to it developing an action plan to address documentation issues and hand hygiene and aseptic techniques. The trust also had three clostridium difficile cases in the first two months of the financial year, against a full year target of no more than 11. Root cause analysis has found no links or recurrent themes.