Medical error at Telford hospital discovered by x-ray

The never event, named so because they are incidents that guidelines say should never happen, was recorded by Shrewsbury and Telford Hospital NHS Trust (Sath).

A report to the trust's board by the quality and safety committee said there was a never event on ward 17 at PRH on March 6.

It said: "A nasogastric tube for the administration of medications was inappropriately placed into the patient’s bronchus.

"Initial investigation indicates that the correct procedure was followed in checking aspirate pH, and the error was discovered only by x-ray, which had been requested for other reasons."

A full investigation is currently underway.

It was the fifth never event to be recorded by the trust in 2018/19.

In February, there was also one serious incident reported involving maternity, according to a quality governance report to the trust board.

The report said: "There was a short delay in recognising that the cardiotocography (CTG) was monitoring the maternal heart rate as opposed to the fetal heart rate.

"When the correct steps were taken for alternate monitoring it was noted that the changes to the fetal heart rate required expedited delivery, which was done.

"At delivery the baby was noted to be pale and floppy with no ‘suck’ reflex.

"The baby met the criteria for active cooling and was transferred to University Hospitals of North Midlands NHS Trust (UHNM) where the baby made a good recovery and is likely to have a positive outcome."

The incident will be investigated by the Healthcare Safety Investigation Branch.

The report continued: "While this has been classified as a moderate harm event within Sath, there has been a request to escalate this and report as a serious incident for the purpose of transparency."

It says, as per guidance, Sath will not investigate alongside HSIB, but local learning has been noted following a 'rapid review' meeting and will be implemented.

Sath's board will discuss the reports when it meets on Thursday.