Queen's Hospital NHS trust records three 'never events' in a month after only recording two last year
PUBLISHED: 07:00 20 June 2019
There were more preventable serious medical mistakes made at Havering's NHS hospital trust last month than there were in the whole of last year, it has been revealed.
The Barking, Havering and Redbridge University Hospitals Trust (BHRUT), which runs Queen's Hospital in Rom Valley Way, Romford, and King George Hospital in Barley Lane, Goodmayes, made the worrying revelation in board papers ahead of a meeting on Wednesday, June 19.
In BHRUT's most recent Quality and Safety Performance Report, written by interim head of quality and safety Ljiljana Maljenovic, it is revealed: "There have been 22 serious incidents declared for the month of May, which is an increase on the previous month's total of 13.
"The quality team have undertaken a review of the incidents due to the increase in number.
"Three of the incidents were generated following formal complaints, three never events were raised and three related to medication incidents."
The NHS defines never events as serious incidents that are wholly preventable if the proper guidance and safety recommendations are followed.
They are, as the name would suggest, never supposed to happen if the correct systems and procedures are followed.
NHS Improvement's data shows there were only two never events recorded at BHRUT's hospitals in 2018/19 - although this data is still awaiting verification.
In both 2016/17 and 2017/18, there were only three never events logged during the entire financial year.
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Last month's three never events all related to foreign objects being left in patients after procedures, and all are being investigated both by the trust and by its external regulators and commissioners.
The trust has been able to confirm that no one involved in any of the three never events suffered any lasting harm.
Kathryn Halford, the trust's chief nurse and deputy chief executive, said: "We are extremely sorry and we have apologised to each of these patients directly.
"Any never event is one too many and we have clearly fallen well below our own high standard of care in these cases.
"None of the patients involved in these incidents were left with any long-term harm.
"Each incident will be thoroughly investigated.
"We will be looking at why it happened, and seeing what can be learned to prevent it from happening again.
"Whenever an incident likes this takes place, once fully investigated we immediately implement any changes to ensure the safety of our patients.
"For example we have introduced 'halt for the count' in our theatres, whereby all staff stop what they are doing while a final count of swab removal is done out loud; implemented theatre boards for swab and instrument counts; and increased staff training including two additional educator posts and introduced simulation exercises."