Surgery on wrong part of body, foreign bodies left in patients - eight '˜never events' recorded at Wigan hospitals

Never events are serious incidents that “wholly preventable” and have the potential to cause a patient serious harm of death.

Events at Wrightington, Wigan and Leigh NHS Foundation Trust recorded included the surgery being carried out on the wrong part of the body and several incidents when swabs or foreign bodies were left in a patient after surgery.

None of these cases resulted in death, but in most further medical care was required.

As well as the eight never events between April 2013 and December 2015, the trust recorded 64 serious untoward incidents (SUI) which can be any incident involving an NHS patient, relative or visitor.

They are investigated internally by the trust and also include a number of incidents originally classed as never events but downgraded following an external inquiry.

These include a number of unexpected deaths either following treatment or shortly after a patient had been discharged from hospital.

In only two cases was the death thought to be as a result of the trust’s actions - in one case after the patient had previously visited A&E and the other due to deterioration and arrest 10 hours after admission. Both happened in 2014.

One patient’s death is listed as due to an self-inflicted injury when they fell from a height causing multiple injuries.

Several neo-natal deaths also feature on the list of SUIs, one was due to sepsis, another died age at just four days old after a delayed transfer to another unit and a third who was just six-weeks-old.

Other concerning SUIs included a failure to act on test results that showed a patient had lung cancer and resulted in them requiring extra medical care, while a number of women were called back for breast screenings after a fault was discovered with the equipment.

No never events were reported between April 2015 and December 2015, although one was de-escalated and 12 were SUIs.

The SUIs included, the wrong tooth being extracted, a regional anaesthetic block applied to the wrong are post-operation and a delayed diagnosis and treatment in cancer.

A WWL spokesman said: “It is very upsetting and distressing for patients and loved ones who are involved in serious incidents or never events.

“At WWL we believe that it is essential to take all incidents seriously and investigate them properly. It is our duty to provide the best standard of care and treatment for our patients.

“We investigate and learn from significant events when things go wrong, whilst carefully avoiding blame.

“In order to achieve this we encourage a culture where raising concerns is normal practice, and foster an environment where they are taken seriously and investigated properly. WWL has a strong duty of candour, alongside openness and transparency.

“This is demonstrated by complainants and their families being involved in investigations; this enables us to improve our services and give a better understanding how to put things right when they go wrong and to understand the impact on the person and their families.

“It is very reassuring that our staff feel confident and secure in reporting unsafe clinical practice and contribute actively towards improvements at work. This aids us in providing the best quality of care for our patients.

“We were delighted to have been ranked 6th in the country for the Department of Health’s first ‘Learning from Mistakes’ report. WWL was one of only 18 Trusts nationally who achieved a ranking of ‘Outstanding’.

“The Department of Health based their data on safety reporting and the NHS Staff Survey. The results demonstrate that quality and putting patient safety first are built into our culture at WWL, and that we really do learn from our mistakes.”

The spokesman said that some of the key outcomes from our approach to make sustained improvements are:

Decrease in Never Events

Decrease in grade three and four pressure ulcers

Decrease in serious harm falls

Decrease in serious incidents over three years

Increase in incident reporting

Significantly above average for percentage of no harm incidents reported

Demonstrable change in safety culture, particularly on our medical assessment wards

“We cannot stress too keenly that we consider that one Never Event is one too many, and we never underestimate the effect on the patients concerned or their loved ones,” the spokesman added.

“It is right for each incident to be reported, investigated and where applicable, lessons be learned. We continue to learn from our incidents, keeping the patient at the centre of everything we do.”

Andrew Wragg, Head of Provider Quality, Wigan Clinical Commissioning Group, Said: “Wigan Borough Clinical Commissioning Group (the CCG) through its established Clinical Governance Framework ensures that the Trust is able to evidence compliance with the NHS England; Serious Incident Framework and the Revised Never Events Policy and Framework (March 2015).

“This enables the Trust to evidence that Serious Incidents and Never Events are investigated and reviewed and importantly any subsequent learning is shared and embedded to mitigate the risk of future recurrence.”