PERFORMANCE: There were three ‘never events’ reported by Wirral University Teaching Hospital Foundation Trust between July and September 2012, according to latest commissioner board papers.

Primary care trust cluster NHS Cheshire, Warrington and Wirral’s December quality report states: “It is of great concern that Wirral University Teaching Hospital has reported three Never Events during quarter 2 (July – Sept 2012). One involved wrong site surgery (radiological procedure), one a retained swab and one wrong implant/prosthesis.

“In the three cases the patient did not experience significant/serious harm. However it is recognised that the incidents were very serious and actions taken to prevent these incidents occurring again include specific raising awareness of the Never Events with relevant teams, changing theatre practice and introducing visual cues, revising induction for radiographers and [reducing] interruptions in [the] interventional suite.”

Never Events are serious, largely preventable patient safety incidents that may result in death or permanent harm, which should not occur if the available preventative measures have been implemented.