(a)   the issue of ‘Never Events’ was taken very seriously.  The Trust would be investing resource to deal with the number of events and the Trust were aware of the critically important duty of candour;

(b)  there were seven ‘Never Events’ in the previous 12 month period, two of which occurred despite national guidance being followed;

(c)   the Trust continued to work with the National Patient Safety Authority to share learning and recommend changes to national guidance;

(d)  the Trust thresholds for reporting serious incidents as ‘Never Events’ were very low. The low threshold applied for both external and internal reporting;

(e)  the Trust were taking steps to ensure that patients, families and staff involved in ‘Never Events’ were fully supported;

(f)    the report which had been provided to the committee outlined immediate actions taken by the Trust to safeguard patients;

(g)   the Trust was committed to the continued open and transparent reporting of all incidents affecting patient safety;

(h)  the recent ‘Never Events’ differed in type and context from those reported previously and the Trust had robust oversight mechanisms in place to ensure that the implementation of learning was effectively enacted and monitored;

(i)    the Trust would continue to promote an open culture with regards to adverse incidents and actively encouraged all staff and patients to report areas of concern.

(j)    bench-marking was fraught with difficulty, no two organisations measured incidents in the same way. Thresholds in the Trust were very low but there was not enough information available across the Country to allow for valid comparisons to be made;

(k)  one “Never Event” was too many and the treatment in Derriford Hospital was safe;

(l)    following the “Never Events” there had been changes to practice, for example, there was a surgical team that did not mark the patient in preparation for radiological procedures and that practice had been changed;

(m)behaviour change and team working had been a key consideration for the Trust. In highly complex procedures the human factor had to be right to reduce errors and work had taken place to reduce distractions and fatigue. Staff received adequate breaks and fatigue of staff was being reduced;

(n)  each event was considered in great detail and it was found that operational pressure increased the risk of incidents,  as a result there had been increased control over shift lengths and scheduling;

(o)  external scrutiny was undertaken by the NHS Trust Development Authority and healthcare commissioners in addition to external clinical opinion;

(p)  recent ‘Never Events’ experienced at the Trust happened with very different procedures then previously reported ‘Never Events’. The learning following the events had uncovered cultural and leadership issues;

(q)  if surgeons used music to aid concentration any member of staff could ask for the music to be switched off. If music became a barrier to communication it needed to be switched off;

(r)   externalscrutineers had advised the Trust that incidents could be downgraded if found not to be ‘Never Events’. The Trust would rather over report than under report and the Trust was now above the national average for reporting;

(s)   it was extremely rare that people were wilfully negligent.  Regarding disciplinary action for failure to follow procedure, the Trust would initially look to see what had gone wrong, identify contributing factors and make a decision on that basis.  If there were a staff failure to respond to support mechanisms in place to ensure protocols were followed, appropriate disciplinary action would be taken. Staff had been disciplined where clear guidelines had been violated.

1.    that the Democratic Support Officer would investigate on whether an Independent Review of Never Events was appropriate; 

2.    that the Democratic Support Officer would work with Plymouth Hospitals NHS Trust to develop a Health Accountability Forum, similar to those being held at Staffordshire County Council.