Cornwall Never Event Investigation Begins

Royal Cornwall Hospitals Trust Launches Investigation Into Preventable Incidents


Executives at the Royal Cornwall Hospitals Trust are investigating so-called never events at one of its facilities.

Three never events, which are described by the NHS as being serious, largely preventable incidents that put patients in danger and should never occur, took place at the Royal Cornwall Hospital in the last month.

One of these accidents involved the removal of an incorrect tooth while a patient was under local anaesthetic.

The person affected was later returned to the clinic in question where the correct tooth was removed.

Details on the other two incidents have not been released, but it is clear that Royal Cornwall Hospitals Trust are keen to ensure that patient safety remains unquestioned at its site, as never events at other trusts have led to serious repercussions, with some even threatened with special measures.

A spokesperson from the CQC said it was satisfied that the trust is taking action to investigate and punish those involved, but added that it will carry out a surprise inspection visit at some point in the near future to ensure patients are not put at risk.

Last month, Royal Cornwall Hospital was told by the authority that it must improve, after failings were found - although other branches of the hospital managed by the same trust were awarded a good rating.

A spokesperson for the Royal Cornwall Hospitals Trust said: "Patient safety is our top priority and we are clear that any never event is unacceptable and are always subjected to a rigorous investigation process to ensure [the trust] and, where appropriate, the wider NHS learns from any incident."

Earlier this month, health minister Dr Dan Poulter visited Royal Cornwall Hospital and expressed his support for the facility, which has a below-average 35-minute wait average at its A&E department.

"The modern facilities are excellent and clearly delivering the improved levels of privacy, dignity and quality of care that were planned for," Dr Poulter added at the time.

Expert Opinion
Never events should be just that, events which just do not happen, and for three very similar instances to occur within the same NHS Trust within a month is simply not acceptable.

“Sadly we have seen a number of repeat incidents of retained instruments, surgery on the wrong body part and cases of wrong implants or prosthesis being fitted. This is despite these having been classed as ‘never events’ by the NHS some years ago.

“The Trust must openly communicate the results of its investigations with the patients affected and prove that lessons have been learned to prevent the same errors from happening again.

“These lessons should also be shared throughout the NHS to improve patient safety across the UK and ensure no other patient is at risk of unnecessary harm.”
Julie Lewis, Partner