Agenda item

PLYMOUTH HOSPITALS NHS TRUST - NEVER EVENTS POST INSPECTION UPDATE

The panel will receive an update following the Care Quality Commission’s most recent inspection.

Minutes:

Consultant Maxillofacial Surgeon and Assistant Medical Director Mr Paul McArdle introduced a report on the work that had taken place across Plymouth Hospitals NHS Trust (PHNT) since the visit of the Care Quality Commission (CQC) following a number of ‘never events’ that had taken place at the hospital.

 

It was reported that –

 

(a)   following an initial visit the CQC had commented that theatre safety checklists had not been carried out correctly and the compliance rates had varied from 20 per cent to 80 percent;

 

(b)   the CQC had since visited Derriford Hospital and were happy with the work that had taken place. The trust had changed working practices and as a result had greatly improved the checklist compliance rates;

 

(c)    theCQC had recognised the shift in practice and had recommended the work PHNT had undertaken to other hospitals around the country who have experienced similar problems.

 

It was further reported that –

 

(d)   on Sunday the 17 July 2011 a further preventable event had taken place. A guide wire used during a procedure to insert a fluid line had been retained within a patient. This event was not covered by the theatre checklist and the event had taken place outside of the theatre environment. The event had no material effect on the longevity of the patient. The patient later died of unrelated causes and the death certificate had been issued, both the coroner and patients family agreed it was not a matter for inquest;

 

(e)   PHNT had been in contact with the family to offer an apology and provided an explanation to what had taken place;

 

(f)     the event was the result of a human non-technical error, the highly experienced clinician was distraught that such an error had taken place;

 

(g)   the hospital had immediately implemented a policy to prevent such an error occurring again. There had been no policy to prevent such an error before the event and the hospital had reported it immediately to the CQC so the nature of what occurred could be disseminated to the wider NHS;

 

(h)   the National Patient Safety Agency had increased the definition of ‘never events’ to include 25 scenarios. It is unclear whether the recent event was classified as a never event under the new criteria as it occurred outside of the theatre setting;

 

(i)     PHNT had implemented a number of policies and processes to prevent such events from occurring. Although the risk of such events would reduce as a result of policy changes, there was always the possibility of human error. PHNT had encouraged an open culture at the hospital and mistakes reported by staff were shared with other agencies.

 

The Chair commended the honesty and openness of PHNT and thanked them for providing the information in a meeting which was open to the public.

 

In response to questions from members of the panel it was reported that –

 

(a)   the event followed the insertion of a fluid line which was an extremely common procedure;

 

(b)   PHNT were not aware of alternative equipment on the market to prevent similar events. The event had been reported to The Royal College of Anaesthetists who had been asked to identify any alternative equipment available;

 

(c)    an investigation would need to take place before details of never events were released to the public;

 

(d)   the theatre structure has been reorganised and PHNT had formed a Patient Safety Group which reported to the PHNT board which was a public meeting.

 

Supporting documents: