Hospitals used by South Holland residents stack up a catalogue of blunders

Queen Elizabeth Hospital at Kings Lynn made six blunders in a year, but has had no never events so far in 2015/16.
Queen Elizabeth Hospital at Kings Lynn made six blunders in a year, but has had no never events so far in 2015/16.

Hospitals used by South Holland residents are making medical blunders regarded as so serious they should never happen.

Queen Elizabeth Hospital (QEH) in King’s Lynn had six ‘never events’ in the year to March 2015, including two cases involving surgery on the wrong part of the body and two involving leaving foreign objects inside the patient’s body.

Although unacceptable and inexcusable, none of the patients were harmed long-term by the incidents

ULHT medical director Dr Suneil Kapadia

United Lincolnshire NHS Trust (ULHT), which runs hospitals including Pilgrim at Boston, made five blunders since 2013 and all involved leaving a foreign object inside the patient. Peterborough and Stamford Trust (PST) had four never events between April 2013 and December 2015.

The spotlight fell on never events on Thursday when the Press Association focused on more than 1,000 cases across England.

NHS England figures show:

• ULHT – April 1, 2013 to March 31, 2014: foreign objects left in patients (2); April 1, 2014 to March 31, 2015: foreign object left in patient (1); provisional figures for October 2015: foreign objects left in patients (2).

A foreign object was left in a patient at Pilgrim between April 1, 2014 and March 31, 2015, an incident reported by Lincolnshire Community Health Services but it appears this is included in the ULHT figures.

Dr Suneil Kapadia, medical director with ULHT, said: “The trust takes never events extremely seriously. We are very disappointed to have had five never events since April 2013.

“Although unacceptable and inexcusable, none of the patients were harmed long-term by the incidents.

“All never events are reported immediately and thoroughly investigated to establish the circumstances, learn from the incidents and change practice to avoid it happening again.”

• QEH – April 1, 2013 to March 31, 2014: wrong site surgery (1); April 1, 2014 to March 31, 2015: wrong site surgery (2), foreign object left in patient (2), maladministration of insulin (1), air embolism (1).

Provisional figures for April 1, 2015 to May 19, 2015 show one inappropriate administration of daily oral methotrexate, but the hospital says this was downgraded to a ‘serious incident’ following official investigations.

Dr Beverly Watson, medical director at QEH, said: “We were disappointed to report a number of ‘never events’ in 2014/15. There have been significant improvements to increase both patient safety and the quality of care across the organisation. Patients and their families who did experience a ‘never event’ were kept regularly informed and updated during our investigations into how the incident occurred, and supported through their subsequent treatment.

“We continue to actively encourage staff to report any adverse incidents so that we can further improve our standards, and are very pleased to report that we have had no ‘never events’ to date in 2015/16.”

• PST – April 1, 2013 to March 31, 2014: wrong site surgery (1); April 1, 2014 to March 31, 2015: wrong site surgery (1), foreign object left in patient (1). Provisional figures for September 2015 show one foreign object was left in a patient.

Joanne Bennis, chief nurse at PST, said: “Patient safety is our main priority and the trust investigates each ‘never event’ thoroughly to identify how it occurred. Once identified, we focus on how this can be prevented in the future and make adjustments to strengthen our processes to ensure that similar incidents do not happen again.”

She said none of the four incidents at PST had resulted in lasting harm to the patient.