Hospital Inspected After 7 Never Events

The Plymouth Herald

April 24, 2013

An inspection is under way at Derriford Hospital in the United Kingdom following seven reported never events in the last financial year.

Independent health watchdog the Care Quality Commission (CQC) has confirmed it sent in a team of six inspectors and two specialists to the city's main hospital last Tuesday.

A spokesperson for the CQC said: "We can confirm that we are inspecting Derriford Hospital. We began the inspection last Tuesday when we sent in a fairly big team. We were due to inspect in May so we brought the date forward. This is not purely because of the reported never events but it is certainly something we will be looking at.

"The inspection is due to last until Friday and it is a longer inspection than we have spent at the hospital before. The never events are things of concern."

As reported in The Herald earlier this month, Ann James, chief executive at Plymouth Hospitals NHS Trust, which runs Derriford, warned trust board members that they should be prepared for an unannounced inspection following the never events. A never event is defined as a serious, largely preventable patient safety incident that should not have occurred if the available preventative measures had been implemented.

Derriford Hospital reported seven never events in the last financial year. The figure is more than three times higher than the previous financial year, for 2011/12, which saw two never events reported.

At the end of March, The Herald reported that five such never events, which had involved surgery or treatment on the wrong part of the body, had been reported since November.

Three of the incidents occurred within a seven-day period last month?on March 12, involving wrong site surgery; March 14, where a wrong site diagnostic procedure was performed; and March 19, when a patient was given a wrong implant.

The other four incidents reported in the last 12 months were reported in July, September, November and January. One incident involved angioplasty treatment?a technique used to widen narrow or blocked arteries. The patient needed the procedure on their left side but it was initially carried out on the right hand side.

At this month's Plymouth Hospitals NHS Trust board meeting Ann James said the trust had met with its regulators the Trust Development Agency, Clinical Commissioning Group and the Devon, Cornwall and Isles of Scilly Local Area Team (LAT) of the NHS Commissioning Board to discuss the never events.

It was also announced that the trust has asked the Trust Development Agency to send in experienced theatre staff to Derriford to help the hospital improve.

The spokesperson for the CQC said they hoped the inspection report would be published in June.

"We'll be speaking to patients, staff and managers," the spokesperson said. "At the end of the inspection we will have a preliminary meeting with the managers to feedback what we found but we won't be able to confirm the findings of the inspection until June."

A spokesperson for Derriford Hospital said they could not comment as the inspection was still ongoing.

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