Agenda item

[Debra Hickman,Deputy Chief Nurse, to present a breifing paper on the work done by The Royal Wolverhampton NHS Trust to learn from ‘never events’]

Debra Hickman, Deputy Chief Nurse, RWHT, gave a presentation about the number and type of ‘never events’ and the learning from a review that would be used to inform future action.

The Deputy Chief Nurse advised the Panel that the NHS definition of a ‘never event’ has changed since 2011 following revised guidance. The Deputy Chief Nurse added, that as result of the changes it was more difficult to make a judgement about changes in the quality of patient care over time.   This was because some previous errors were no longer classified as a ‘never event,’ which needed to be reported.  The Deputy Chief Nurse explained that some incidents were not recorded in the year that they occurred, which could affect the annual reported figures.

The Deputy Chief Nurse advised that work was being done to standardise the data to improve the situation.  The Deputy Chief Nurse reassured the Panel that there was no evidence to suggest that current systems and checks were at fault – work was being done to encourage greater openness among medical staff involved in invasive surgical procedures. The Deputy Chief Nurse gave an analysis of the data presented and the common themes identified as contributing to the number of reported incidents.

The Deputy Chief Nurse advised the Panel that policies and procedures had been revised and that findings from the causes of ‘never events’ were used to inform future practice – the work would include reviewing the patient pathway and supporting an environment which encouraged personal reflection and revalidation of staff to improve practice. The Deputy Chief Nurse commented on the difficulties in achieving compliance in terms of practice and greater understanding of hospital procedures, by using permanent staff rather than agency staff.  An update on action to deliver safer care would be included in the hospital’s next Quality Accounts report.  The Panel thanked Debra Hickman for her presentation.

The Panel queried the reasons for the increase in the number of recorded wrong site incidents as ‘never events’. The Deputy Chief Nurse explained that nationally there was an issue about the underreporting of wrong site incidents – where a procedure would have been necessary at a future date it was not always recorded as a ‘never event’. The issue of consent was key – as the patient has agreed to a specific surgical procedure and if an operation had been done on the wrong site, then this should be counted as a ‘never event’.

The Panel discussed the common themes contributing to ‘never events’ and the extent to which poorly trained staff were a factor.

David Loughton, Chief Executive, RWHT commented on the investment in surgical simulation suites to allow surgeons to practice procedures. The Chief Executive added surgical procedures were complex and people could make errors which had consequences for patients.  The Chief Executive supported the reasons made by the Deputy Chief Nurse for not using agency doctors and nurses during surgery.

The Panel commented on the issue of human error which appeared as a common link in a list of themes in the presentation.  They queried whether it was an issue of lower graded staff not feeling able to report senior staff, where they had concerns about their competence. The Chief Executive commented that the hospital was a good place for medical students to learn and the hospital was rated as offering a good learning experience. The Chief Executive commented on the work done to learn from the aircraft industry to reduce the number of accidents and the management of risks and variations in practice.

The Panel queried at what stage a person would be likely to be dismissed because of a ‘never event’. The Chief Executive responded that each case would be judged on its own merits and that there was a set process before a surgeon was referred to the General Medical Council and this was rarely due to an individual error but a combination of varied factors. 

The Chief Executive commented that following a recent inspection by CQC the hospital has been rated as being good and a similar rating was expected for Cannock Hospital. The good CQC assessment rating had made a positive impact on the recruitment at the hospital.

Resolved: That the report from the Royal Wolverhampton Health Trust on ‘never events’ be noted.