• Trust has had seven never events since April 2018, with six reported after invasive procedures
  • No single root cause identified but trust papers highlight “issues in relation to teamwork and behaviours”
  • Trust implementing a training programme developed for staff involved in invasive procedures

A major London teaching trust has accelerated a trust-wide training programme after reporting seven never events in its financial year to date, including two in one month. 

Imperial College Healthcare Trust developed the action plan after four never events were recorded between June and November. It had to reassess the plan, including speeding up its rollout, after a fifth never event was reported in December, followed by two more in early January.

Six of the seven never events in 2018-19 followed invasive procedures and related to wrong site surgery, wrong site block or a retained foreign object. The seventh was for medication administered through the wrong route.

The trust has not identified a root cause for the never events, which occurred in five separate specialities on different sites run by the trust. However, board papers from the trust’s March meeting revealed feedback from staff after the never events suggested there were “issues in relation to teamwork and behaviours”.

The provider has developed a simulation and coaching programme that “will support improvements in these areas for staff involved in invasive procedures”.

Staff in the five specialities which reported never events have begun the training programme. The next step will be to roll out the programme to all specialities involved in invasive procedures.

The trust is reviewing its invasive procedures policy and count policy, to make sure they are “in line with national guidance and are audited”. It has also taken steps to improve compliance with safety procedures, including planning audits of its existing procedures and policies.

Julian Redhead, the trust’s medical director, said in a statement: “We take ‘never events’ extremely seriously and recognise the impact they have on patients and staff.”

Professor Redhead continued: “We investigate each case thoroughly and have put in place a comprehensive trust-wide action plan which includes an innovative coaching and simulation training programme for all staff involved in invasive procedures to help them continually improve.”