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| Plymouth hospital gets formal warning after eight 'never events' in year | Plymouth hospital gets formal warning after eight 'never events' in year |
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| A hospital has failed to ensure the safety of patients, the care watchdog has said, after an investigation into eight serious mistakes in the past year. | A hospital has failed to ensure the safety of patients, the care watchdog has said, after an investigation into eight serious mistakes in the past year. |
| Plymouth Hospitals NHS Trust has been told to make urgent improvements to protect patients undergoing surgery at Derriford hospital, which has the second highest number of "never events" – so called because they should never happen – in England in the last four years. | Plymouth Hospitals NHS Trust has been told to make urgent improvements to protect patients undergoing surgery at Derriford hospital, which has the second highest number of "never events" – so called because they should never happen – in England in the last four years. |
| The Care Quality Commission (CQC) issued a formal warning to the trust after an unannounced inspection in which it failed to meet five of the nine national standards reviewed. | The Care Quality Commission (CQC) issued a formal warning to the trust after an unannounced inspection in which it failed to meet five of the nine national standards reviewed. |
| The inspection was triggered by a spate of never events, many involving surgery or treatment to the wrong part of the body. Three incidents occurred within a seven-day period: on 12 March, involving wrong-site surgery; 14 March, when a wrong-site diagnostic procedure was performed; and 19 March, when a patient was given a wrong implant. | The inspection was triggered by a spate of never events, many involving surgery or treatment to the wrong part of the body. Three incidents occurred within a seven-day period: on 12 March, involving wrong-site surgery; 14 March, when a wrong-site diagnostic procedure was performed; and 19 March, when a patient was given a wrong implant. |
| In another never event, medics began performing an angioplasty – an operation to widen narrow or blocked arteries – on the right side of a patient who was meant to have the procedure on their left side. | In another never event, medics began performing an angioplasty – an operation to widen narrow or blocked arteries – on the right side of a patient who was meant to have the procedure on their left side. |
| A team of inspectors spent two weeks at the hospital in April following up concerns. They found that the way in which operations were scheduled was putting staff under too much pressure, raising the risk of mistakes. | A team of inspectors spent two weeks at the hospital in April following up concerns. They found that the way in which operations were scheduled was putting staff under too much pressure, raising the risk of mistakes. |
| Clinical staff said the timetables were unrealistic and did not make allowance for any unexpected incidents that could cause delays. When the surgery list over-ran, staff might cut corners to save time and staff shortages meant specialist theatre staff were often not available. | Clinical staff said the timetables were unrealistic and did not make allowance for any unexpected incidents that could cause delays. When the surgery list over-ran, staff might cut corners to save time and staff shortages meant specialist theatre staff were often not available. |
| Although the trust has been under the spotlight for poor performance for two years, inspectors said it had failed to learn the lessons well enough. In February 2011 a series of six never events prompted the CQC to warn that without immediate action the trust could face prosecution or the closure of its operating theatres. | Although the trust has been under the spotlight for poor performance for two years, inspectors said it had failed to learn the lessons well enough. In February 2011 a series of six never events prompted the CQC to warn that without immediate action the trust could face prosecution or the closure of its operating theatres. |
| The CQC said the trust had identified the same issues but the necessary changes had not been made. The trust has a week to respond. | The CQC said the trust had identified the same issues but the necessary changes had not been made. The trust has a week to respond. |
| The trust's chief executive, Ann James, said a surgeon was now in charge of theatres, supported by a matron, and the hospital had in place "a full theatre improvement plan led by our new director of nursing". | The trust's chief executive, Ann James, said a surgeon was now in charge of theatres, supported by a matron, and the hospital had in place "a full theatre improvement plan led by our new director of nursing". |
| She said: "If you are coming into hospital for an operation here, you are in safe hands. Last year nearly 39,000 patients were operated on at Derriford hospital. We reported eight never events in that year. Most hospitals have reported some never events." | She said: "If you are coming into hospital for an operation here, you are in safe hands. Last year nearly 39,000 patients were operated on at Derriford hospital. We reported eight never events in that year. Most hospitals have reported some never events." |
| In a speech last month the health secretary, Jeremy Hunt, said the NHS must tackle the "silent scandal" of errors that meant 3,000 patients died needlessly last year. "Every other day we leave a foreign object in someone's body, every week we operate on the wrong part of someone's body, and every fortnight we insert the wrong implant," he said. | In a speech last month the health secretary, Jeremy Hunt, said the NHS must tackle the "silent scandal" of errors that meant 3,000 patients died needlessly last year. "Every other day we leave a foreign object in someone's body, every week we operate on the wrong part of someone's body, and every fortnight we insert the wrong implant," he said. |
| However, experts are split over the value of comparing hospitals by never events, pointing out that the system relies on trusts voluntarily reporting incidents of harm. Brian Jarman, a professor at Imperial College London, who co-founded the health statistics and research service Doctor Foster, said: "It's a joke among researchers that if you are asked which hospital is the safest to go to you'd probably pick the one with the highest number of never events because they had the best reporting systems." | However, experts are split over the value of comparing hospitals by never events, pointing out that the system relies on trusts voluntarily reporting incidents of harm. Brian Jarman, a professor at Imperial College London, who co-founded the health statistics and research service Doctor Foster, said: "It's a joke among researchers that if you are asked which hospital is the safest to go to you'd probably pick the one with the highest number of never events because they had the best reporting systems." |
| Jarman said Hunt's figures were an underestimate. "The Bristol inquiry [into child deaths] more than two decades ago said the figure was more likely to be nearer 25,000," he said. | Jarman said Hunt's figures were an underestimate. "The Bristol inquiry [into child deaths] more than two decades ago said the figure was more likely to be nearer 25,000," he said. |
| A Department of Health spokesperson said: "There is no excuse for services to fall short of the standards that we and patients expect. Substandard care cannot be tolerated and we expect the trust to work closely with the CQC and take any steps needed to improve care. | A Department of Health spokesperson said: "There is no excuse for services to fall short of the standards that we and patients expect. Substandard care cannot be tolerated and we expect the trust to work closely with the CQC and take any steps needed to improve care. |
| "Nursing leaders have been clear that hospitals should publish staffing details and the evidence to show the numbers are right for the services they deliver." | "Nursing leaders have been clear that hospitals should publish staffing details and the evidence to show the numbers are right for the services they deliver." |
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