Hartlepool Hospital Reveals Near Miss With Never Event

Trust Reveals Doctor Nearly Operate On Wrong Body Part

01.05.2014

The University Hospital of Hartlepool has revealed details of a "near miss" where a patient almost had the wrong part of their body operated on by doctors.

Although the person, who has not been identified, was not harmed and the error was spotted before any action was taken to begin the operation, it has been referred to as a "never event", which the NHS has tried to cut out in recent years, reports the BBC.

Never events are mistakes that are, according to the Department of Health, "wholly avoidable" and could result in serious harm if not spotted.

A number of trusts have been criticised by media in recent months for never events, including a recent mistake at the Royal Cornwall Hospital where a patient had the wrong tooth extracted in an operation.

Speaking about the University Hospital of Hartlepool near miss, councillor Stephen Akers-Belcher, who is the vice-chairman of Hartlepool Council's Audit and Governance Committee, said: "As soon as I was alerted I asked the trust to come forward to a formal meeting of the scrutiny function of the council so that we can question them about the incident and make sure safeguards are in place for the future."

David Emerton, medical director at the trust, added: "We have an open culture. All incidents are reported, investigated and lessons are shared and learned irrespective of their seriousness."

However, Mr Akers-Belcher was keen to press the trust on taking action, stating that if trust executives do not meet with council members in the near-future, the matter could be referred to secretary of state for health Jeremy Hunt, who could sanction the hospital.

Last month it was revealed that the University Hospital of Hartlepool would undergo a centralisation process after parts of the site were described as a "ghost town" by the local Hartlepool Mail.
Part of this scheme will likely involve the downsizing of some existing facilities.

Expert Opinion
Thankfully the patient came to no harm in this instance, but there must be measures in place to prevent such close calls from occurring.

“Never events should be just that, events which just do not happen yet 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.

“Each hospital Trust is aware of what constitutes a ‘never event’ and all staff should follow the protocols that are in place to ensure patients are not put at unnecessary risk.

“We hope that the Trust will meet with the Council to discuss the incident and highlight what steps have been taken to protect the safety of future patients.”
Lisa Jordan, Partner