Medical ‘never events’ included a hospital operating on wrong side of patient’s body

SHOCKING BLUNDERS REVEALED IN BOARD’S PAPERS

A NOTTINGHAM hospital operated on the wrong side of a patient during one of four failed procedures that should have never happened.

Four serious “never events” were recorded at Nottingham’s Queen’s Medical Centre and City Hospital from April 1, 2023 to February 29, 2024, according to NHS England.

Never events are serious, largely preventable patient safety incidents that should never happen if healthcare providers have followed national guidance or safety recommendations. Nottingham University Hospitals NHS Trust, which runs the city’s two hospitals, initially said it could not release what happened during these incidents as it would breach the Data Protection Act.

However, the trust has itself detailed three of the important failings in its board papers over the past year. A “wrong side” never event took place in June 2023, according to NUH’S board papers. This failing was declared in July 2023 and was still being reviewed as of November last year. The papers also showed a naso gastric tube, which is used to give patients nutrition and hydration, was “misplaced” inside a patient sometime in August, last year.

NHS guidance states this type of never event occurs when the incorrect placement of the tube is not noticed before a feed, flush or medication administration starts. NUH board documents explained a review would be undertaken to assess how to prevent this happening to other patients.

A chest drain, a tube which is used to remove air, fluid, blood or pus, was inserted into the wrong place on a patient in October 2023. This was declared as a never event in November 2023, with this becoming the fourth of the 2023/24 period.

NUH did not clarify what had happened during the third never event. A spokesperson for Nottingham University Hospitals NHS Trust said: “We actively encourage our staff to report never events, and they are reported to our Trust Board and relevant regulators. If things go wrong, we tell patients and relatives what happened, apologise and explain what actions will be taken to prevent any recurrence in the future.

“We have clear and robust processes and policies in place to reduce the risk of never events happening and to ensure that we provide the safest possible care to our patients. Never events are rare. If one occurs, we use the national framework to investigate and to learn from what went wrong to inform future practice.”

Sherwood Forest Hospitals NHS Foundation Trust, which runs King’s Mill Hospital, had one never event in the same time period. Phil Bolton, chief nurse at Sherwood Forest Hospitals, said: “Keeping patients safe is our top priority and we take this kind of incident very seriously as a single event of this nature is one too many.

“While they should never happen, we actively encourage staff to report them when they do occur so we can learn from what went wrong and reduce the risk of it happening again in the future.

“We work with the patients and families affected, as well as our staff, to understand what happened, ensure they are all properly supported, and consider how we can further improve the care we provide to the tens of thousands of patients we come into contact with every year.”