Sunday 5 June 2011

Royal Cornwall Hospital under investigation over surgery errors

A powerful health watchdog has launched an investigation into surgery at a Cornish hospital after a potentially catastrophic "never-event" took place in an operating theatre – the fifth in two years.

Inspectors from the Care Quality Commission (CQC) made an unannounced visit to the Royal Cornwall Hospital on Wednesday after health chiefs owned up to the grave breach of patient safety.

The team is now considering what action – which could include ordering surgery to cease immediately, or even a prosecution – to take.

Graham Webster, vice-chairman of the campaign group Health Initiative Cornwall, said he was "extremely disappointed" that the incident had happened.

"The name implies what it is, that this event should never happen at any hospital, anywhere, including Cornwall," he said.

The so-called "never-events" are errors which may or do result in severe harm or death to patients.

Crucially, they are deemed avoidable if proper procedures had been followed.

Full details of what happened have not been disclosed, although it is understood that it was one of two separate instances this year, the latest occurring in April. This second "never-event" concerned the interpretation of the widely used World Health Organisation checklist for surgery.

According to the NHS National Patient Safety Agency's core list of "never-events", this checklist is relevant in preventing errors like surgery on the wrong limb or organ, leaving a surgical instrument inside a patient or the in-hospital death of a mother as a result of a haemorrhage after elective caesarean section.

CQC communications manager Nick Kerswell confirmed that a team of inspectors had visited the hospital, and that an investigation was now under way.

"We are in the process of considering all the information we have gained as a result of our inspection. We will decide over the next few days what action we are going to take as a result," he said.

A Royal Cornwall Hospitals Trust spokesman said there had been five "never-events" at its hospitals over the last 25 months, including two in 2011. All were in operating theatres.

He said any "never-event" was "totally unacceptable" and that the trust had acted to ensure all surgical theatres abided by the checklist.

"We will ensure further training and discussion with our staff to avoid 'never-events' happening in the future," he said.

Source: This Is Cornwall


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