Surgery on the wrong part of the body and objects left in patients after procedure, these are some of the 24 “never events” reported at Greater Lincolnshire’s hospitals over the past three years.
The errors, known as never events due to their severity, are recorded as serious incidents which are wholly preventable with the potential to cause significant harm or death.
According to data from NHS Improvement, both United Lincolnshire Hospitals Trust and Northern Lincolnshire and Goole NHS Foundation Trust reported a total of eight incidents so far in 2019/20.
Incidents recorded included wrong implants given to patients and misplaced naso or gastric tubes.
Health bosses at both trusts said they take never events “extremely seriously” and investigate them fully.
‘Never events’ in Lincolnshire’s hospitals
Since 2017/18, a total of of 17 never events have been recorded at Lincolnshire’s hospitals.
The incidents include administration of medication by wrong route and “retained foreign objects”.
Other incidents included two cases of mis-selection of high strength Midazolam during conscious sedation in 2018/19.
Meanwhile, the trust recorded two cases of wrong site surgery, which is defined as a procedure on the wrong part of the body or wrong person, in 2017/18.
So far this year, seven never events have been reported at the county’s hospitals.
The figure is the second highest recorded in the country, along with Sheffield Teaching Hospitals NHS Foundation Trust.
Most recent data, which includes incidents between April and November 2019, shows two incidents of “retained foreign objects”.
This can include objects such as swabs, needles or guide wires, left inside patients following a procedure.
Dr Neill Hepburn, medical director at ULHT, said: “The trust takes never events extremely seriously.
“As a trust, we report never events immediately and these are thoroughly investigated to establish the circumstances, identify what happened and how we can learn from the incidents and make changes to practice to minimise the risks of it happening again.
“The outcomes of our investigations are shared internally and with our external regulators.”
Northern Lincolnshire hospital’s ‘never events’
Over the last three years, seven never events have been recorded at Northern Lincolnshire and Goole NHS Foundation Trust.
The trust, which runs Scunthorpe and Grimsby Hospitals, has one incident of wrong site surgery recorded this year.
The case was among the most common reported at both trusts, with 10 events recorded across both trusts over the three years.
Meanwhile in 2018/19 NLaG reported a total of three never events, including one case of a swab being left inside a patient following surgery.
A foreign object case was also reported in the previous year, while an incorrect size implant and misplaced naso-gastric tube were also recorded.
Dr Peter Reading, chief executive at NLaG, said the trust takes never events seriously and safe care was “a priority” at its hospitals.
“We’re very sorry these seven patients did not get the care or service they had a right to expect,” he said.
“We make every effort to learn from what happened when we have a never event.
“This means we treat each one as a serious incident taking a long hard look at what happened and why.
“We hold a first meeting quickly to run through what happened and to identify whether we need to change anything straightaway, we then undertake a more thorough and in-depth investigation which would make recommendations, where needed, and what we should differently.
“We implement those changes and then monitor that they are happening.
He added that the trust’s “number one priority is to provide excellent patient care” and that it “continuously strives to provide better and safer care”.
302 never events have been reported at health trusts across the country so far this year, according to NHS Improvement.
Since January 2018, the health service removed the option for commissioners to impose fines when an incident was reported.
NHS Improvement said the policy “reinforced blame culture” and that the concept of never events is “not about apportioning blame”.
SUBSCRIBE TO LOCAL DEMOCRACY WEEKLY, our exclusive email newsletter with highlights from our coverage every week and insights and analysis from our local democracy reporters.