Shrewsbury and Telford hospitals report safety breaches

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Shropshire's two main hospitals have reported six serious breaches of patient safety since last April.

The so-called "never events" at the Royal Shrewsbury and Telford's Princess Royal hospitals were reported at a cluster group board meeting on Tuesday.

"Never events" are classed as the most severe breaches of patient care, such as major surgical mistakes and are considered preventable.

The most recent breach was two weeks ago and related to an eye treatment.

The hospital trust confirmed it was investigating that incident, along with another recently reported, but dating back to July.

In both cases wrong lenses were inserted during cataract operations.

Chief Nurse Vicky Morris said: "As a result of these incidents, the patients will still have experienced a significant improvement in their eyesight but not to the level that we or they had expected.

"We have discussed this with the patients concerned and have apologised to them. These incidents are still under review and we will take appropriate action based on the findings of that review."

In total, three of the six "never events" reported since April are linked to treatments for eye-related illnesses.

Sue Doheny, from West Mercia Cluster Primary Care Trust (PCT) said any "never event" was unacceptable.

'Zero tolerance'

The cluster covers hospitals and healthcare providers in Shropshire, Herefordshire, Worcestershire and parts of south Staffordshire and Gloucestershire.

Start Quote

Never events should become just that - events that never happen”

End Quote Shrewsbury and Telford Hospital NHS Trust

In August, a guide wire was also left inside a patient's chest after surgery to insert a drain, while in December a swab was left inside another patient.

The cluster PCT said a review revealed the hospitals were using an amended version of the World Health Organisation (WHO) surgical checklist and recommended that the original checklist was followed instead.

According to the PCT the hospital trust has made an assurance to use the original checklist in all surgical procedures by the end of February.

The PCT said it was committed to a zero tolerance policy towards "never events".

Chairman of the cluster, Eammon Kelly, said at the board meeting that the hospitals should consider disciplinary action where necessary.

The Shrewsbury and Telford Hospital NHS Trust said it was committed to reducing surgical complications. It added: "Never events should become just that - events that never happen.

"On the rare occasions when a never event occurs within the trust, the situation is fully discussed with the patient and a full apology given on behalf of the trust. Action is then taken that aims to prevent them from happening again."

Shropshire's Robert Jones and Agnes Hunt Orthopaedic Hospital was also given a failure rating after recording one "never event" relating to surgery involving a wrong implant or prosthesis.

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