“These are events that should never happen" - Five serious safety incidents occurred at Portsmouth Hospitals University NHS Trust between April and August
Five serious and preventable patient safety incidents occurred at a Hampshire NHS Trust between April and August this year.
The incidents, known as ‘never events’ were logged at Portsmouth Hospital University NHS Trust which runs Queen Alexandra Hospital in Cosham. It was recorded that two patients underwent wrong site surgery, two received a wrong implant or prosthesis, and one person retained a foreign object post procedure.
The information came to light following a Freedom of Information request submitted by Blackwater Law, a team of medical negligence and serious injury solicitors. However, due to patient confidentiality the exact details of the incidents have not been released just the categories in which they come under.
NHS England defines ‘never events’ as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations”. They are used as a way for NHS Trust’s to learn from mistakes, while also flagging that the implementation of existing safety advice may not be robust.
Jason Brady, partner at Blackwater Law, said: “These are events that, by their name, should never happen. It must be remembered that behind each event there is a person whose life has been affected and that these are events that can be avoided.”
NHS England list wrong site surgery as an “invasive procedure on the wrong patient or at the wrong site” such as the wrong limb. This can include anything from wrong site for pain relief to an issue with a cardiology procedure.
While a wrong implant or prothesis could relate to a contraceptive device, lens in eyecare, and much more. The retention of a foreign object could be a swab, instrument, needle, or anything else left behind during surgery that was not meant to be there.
Hayley Peters, Chief Nurse at Portsmouth Hospitals University NHS Trust said: “Providing the safest and highest quality patient care remains a top priority. Whilst these ‘never events’ did not result in severe harm, they are all taken very seriously, and we must learn from them.
“All the ‘never events’ went through our PSIRF process and had full investigations. We have further increased our focus on patient safety and have a dedicated senior clinical team in place who leads on supporting our teams to learn from significant incidents.
“We always ensure a senior member of our clinical team speaks to a patient who has been affected by a ‘never event’ to ensure we address any of their questions or concerns."
Further information on ‘never events’ can be found on the NHS England website.