More 'never event' errors are revealed at Telford and Shrewsbury hospitals
Three serious medical 'never events' have happened in the last month, according to the trust that controls Shropshire's two main hospitals.
They included two patients not having a guide wire removed after an invasive procedure and a patient being discharged after sinus surgery with ribbon gauze in the nostril.
Shrewsbury and Telford NHS Trust has now reported six so-called 'never events', named so because they are incidents that guidelines say should never happen, since September last year. Health officials say never events are very serious incidents that are considered wholly preventable.
Bosses at SATH say they are planning to review all relevant procedures immediately in view of the continued occurrence of never events.
It revealed three incidents, involving the guide wire and ribbon gauze, happened in separate procedures carried out at Royal Shrewsbury Hospital in October. The patients involved were recalled for further treatment.
The latest incidents follow another two serious mistakes reported by the hospital trust at the end of 2015 and another in August 2016.
The first never event at the trust in more than three years was an incident which involved surgeons removing the wrong skin lesion in September 2015 at Telford's Princess Royal Hospital. The
In November, a swab was left inside a patient's throat after they underwent surgery at Royal Shrewsbury Hospital. The throat swab was removed as soon as it was discovered and the patient was unharmed. A follow-up report suggested the mistakes could have been made due to how busy theatre staff were that day.
In August this year a patient had the wrong tooth removed. A consultant attempted unsuccessfully to re-implant the tooth.
A report due to be discussed at Shropshire Clinical Commissioning Groups' board meeting next week says a case review is carried out for every never event identified.
It states: "Each case review is chaired by the relevant representatives of the provider executive team, relevant provider staff involved in the event, and the patient involved in the event is also invited to attend with clinical support being provided by the senior clinical team within the trust.
"The trust has extended an open invitation to commissioners to attend these reviews.
"The trust has recently indicated to commissioners their intention to review all appropriate procedures immediately in view of the continued occurrence of never events."
A Sath spokesman said that while investigations were ongoing it did not wish to comment. The issue will be discussed by Shropshire CCG on Wednesday in Shropshire Education and Conference Centre.
