• South Tyneside and Sunderland FT reported three never events in the same month
  • Trust says there was no “immediate” or “severe” harm to patients involved
  • Root cause analysis is now underway

Investigations have been launched after three “never events” were recorded in one month at a north east acute trust.

Board papers published by South Tyneside and Sunderland Foundation Trust showed the incidents all occurred during May this year.

Two were wrong site surgery incidents and the other involved an incorrect implant or prosthesis.

HSJ asked STSFT for specific details on the incidents, but the trust declined to provide more information.

Minutes from the board meeting said: “[Chief executive Ken Bremner] was disappointed to have to report to the board that there had been three never events since the beginning of the financial year – two wrong site surgery incidents and one implant incident.

“He advised there had been some concern in relation to how these had been flagged which were being picked up.”

A spokeswoman for the trust said: ”Detailed and separate root cause analysis investigations are underway in relation to each of the three serious incidents however we can confirm that there was no severe harm caused to any patients.”

All the patients have received an apology.

The trust added: “We continue to raise awareness amongst staff of the systems and safeguards we have in place to prevent never events from occurring, and openly encourage all staff to report any incidents – no matter how big or small – so we can continue to learn, improve and embed a positive and safe learning culture across our new trust.

“We have an open and honest learning culture and our staff are being supported in learning from these incidents,” the trust said.

A serious incident was also reported during the month of May, described as a “retained object”, but this apparently did not meet “never event” criteria.

Never events are serious incidents or errors in medical care which are avoidable due to best practice guidelines and recommendations.

*Updated 3pm 29 July 2019 to reflect new information provided by the trust showing multiple investigations are underway rather than one single investigation.

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