PERFORMANCE: An incident of drugs being given inappropriately to a patient led to no disciplinary action or referrals to relevant professional bodies, despite being listed as a “never event”.

The incident, of inappropriate administration of daily oral methotrexate, was reported at Heart of England Foundation Trust in June 2012. The risk of harm to the patient was believed to be low due to the low dosage.

Birmingham and Solihull primary care trust cluster board papers said there had no disciplinary action or referrals to relevant professional bodies for any of the staff involved in the incident.

There were also no specific discussions relating to methotrexate during appraisals.

The papers said the drug was not normally used within the clinical environment where the never event occurred.

In another never event, the trust also recorded an incident of “wrong site surgery” for a laparascopic adrenalectomy.

The cluster papers said that throughout the patient’s medical records, there was an “inconsistent approach to clinicians recording the location/side of the adrenal abnormality”.