05.03.18
CQC completes investigation after series of never events at Devon trust
The CQC has completed a review into never events at the Royal Devon and Exeter NHS FT following a series of seven such incidents over the course of two years.
Investigators found a “culture of openness and honesty” at the trust despite the issues, with the events often quickly acted upon and investigated.
It was decided that there would be an examination into the trust after the seven never events were reported alongside two other serious incidents, which were already under inspection.
Never events are classed as any serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented.
Explaining the review, Mary Cridge, CQC head of hospital inspection for the south west, said: “Whenever a serious safety incident occurs, it is essential that the opportunity is taken to learn from the event so that steps can be taken to stop the same mistake happening again.
“At the Royal Devon and Exeter NHS Foundation Trust we found there was a culture of openness and honesty with staff being very aware of their responsibilities to report and act on incidents raised. In general Incidents were acted upon and after investigation, learning was identified to mitigate and reduce further risk.
“For example, following a wrong site surgery in the ophthalmology department an action plan was identified. The action to improve practice included ensuring when only one eye required laser treatment, only that eye should be dilated. Each action had a clearly defined person responsible for its completion and the date this should be achieved.”
While the majority of the trusts practices were applauded, the report did have some reservations about communications between departments, with Cridge questioning whether different specialisations had shared advice.
In addition, inspectors found that there were some occasions where patient’s consent was not always gained before the day of surgery, in line with recommendations made by the Royal College of Surgeons (RCS).
In response to the report, Em Wilkinson-Brice, deputy chief executive and chief nurse at the trust, said: “While we feel that this report by the CQC is fair, we want to reassure the public that the trust takes the reporting of any incident, but in particular never events, extremely seriously. We have a robust process for undertaking duty of candour with our patients and regulators and for investigation and learning from such events.
“We welcome this report’s findings and we will use them to support our culture of continuous improvement for the benefit of all our patients.”
The inspection was a specialised focus review of services, meaning the trust will keep the ‘good’ rating it achieved in 2016.
NHE has contacted the trust for comment.
Top image: Barry Batchelor PA Archive
Have you got a story to tell? Would you like to become an NHE columnist? If so, click here.