An outstanding rated trust had 10 never events in 2017-18 – including four involving wrong site surgery.
Frimley Health Foundation Trust had two further incidents of wrong site spinal surgery, which were initially treated as never events but then downgraded in line with the latest national guidance on never events. A thirteenth incident took place that the commissioner felt was not a never event.
In 2016-17, the trust had four never events and in 2015-16, there were six.
The trust said none of the events in 2017-18 resulted in severe or long term harm but its board papers for February show, of the seven cases reported at that time, six resulted in minor harm and one in moderate harm.
The 10 never events were:
- one wrong site nerve block in anaesthetics;
- one wrong route administration of an oral medication;
- two wrong implants (ophthalmology and cardiology);
- four wrong site surgeries (dermatology, urology, dental and critical care); and
- two retained products in obstetrics and theatre.
In November, the board was told there had been three wrong site surgeries in orthopaedics since April and there had been “a significant change in practice” after route cause analysis of the cases. The trust said two of these examples were the spinal surgery cases – no longer being treated as never events – and the third was a retained screw that was downgraded by commissioners.
A trust statement said: “The trust takes any incident very seriously and particularly never events. We believe in being open and transparent when they occur and we share any learning internally and with our external partners. All have either been investigated or are currently under investigation using the nationally recognised root cause analysis tools.
“Those completed have action plans in place that are monitored through a variety of committees both internally and externally by our commissioners.”
Board paper and trust statement