Wrong tooth pulled out in Shropshire ‘never event’
A dental ‘never event’ was reported at a trust running Shropshire’s community health services.
The never event, so named because they are incidents that guidelines say should never happen, was recorded by Shropshire Community Health NHS Trust and involved a patient having a wrong tooth extracted.
The trust provides community-based health services as well as running community hospitals in Bishop’s Castle, Bridgnorth, Ludlow and Whitchurch.
The details of the never event were included in a report to Shropshire’s clinical commissioning group, which meets in Shrewsbury today.
It said: “The trust has reported a dental never event when a wrong tooth was extracted.
“The CCG have received the root cause analysis report and this is scheduled to be reviewed by the CCG’s serious incident committee.”
The never event was recorded by the trust in November last year.
The month before, Shrewsbury and Telford Hospital NHS Trust reported a never event in ophthalmology, which deals with the diagnosis, treatment and prevention of diseases of the eye and visual system.
Bosses said it involved a locum surgeon implanting the wrong lens on a patient following cataract surgery, but the impact had been “negligible”.
Chief executive of the trust, Simon Wight, said the locum had their contract “terminated immediately”
Shropshire Community Health NHS Trust is expected to be acquired by another organisation this year.
Two trusts are in the frame – Shrewsbury and Telford Hospital NHS Trust and South Staffordshire and Shropshire Healthcare NHS Foundation Trust.
The community health trust was formed after the merger of Shropshire County Primary Care Trust and Telford and Wrekin Primary Care Trust in 2011.
It provides a range of community-based health services for adults and children in Shropshire, Telford and Wrekin, and some services to people in surrounding areas.
Its services range from district nursing and health visiting, to physiotherapy and specialist community clinics.
Chris Hudson, spokesman for Shropshire Community Health NHS Trust said: “Events of this nature are extremely rare.
"As soon as this incident occurred, we discussed it with the patient, apologised and agreed a plan with them.
“When any incident happens, we always investigate thoroughly to ensure lessons are learned and shared. In this particular case we have changed some of our procedures.”