Care Quality Commission finds that Derriford Hospital has responded to safety concerns in operating theatres

1 April 2011

Inspectors report improvements following original finding that Plymouth Hospitals NHS Trust was failing to meet three essential standards.

The Care Quality Commission has said it is satisfied that surgical teams at Plymouth Hospitals NHS Trust have made safety improvements which were required in its operating theatres.

Inspectors who made an unannounced visit to Derriford Hospital this week found that important check-lists recommended by the World Health Organisation (WHO) and the National Patient Safety Agency (NPSA) were now being effectively used in all operating theatres.

The visit followed concerns which were raised initially through the South West strategic health authority after the trust reported six "Never Events" within six months in its operating theatres. Never events are serious, largely preventable incidents which should not happen.

In response, CQC inspectors, accompanied by a professional clinical advisor, visited the hospital in February. Inspectors talked to staff and observed procedures in seven operating theatres, including two day-case theatres and the emergency theatre.

The report of that inspection is published today. At the time, the trust was found to be in breach of three essential standards:

• People should get safe and appropriate care that meets their needs and supports their rights. The inspectors said that patients were at an increased risk because important safety check-lists were not always being effectively used in some operating theatres.
• Staff should be properly trained and supervised, and have the chance to develop and improve their skills. The report said that the working environment, behaviour of staff and practices in some theatres did not promote an environment where clinical excellence could flourish. Although changes were being made, further improvements were needed to improve the safety for patients undergoing surgery.
• The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care. Inspectors said that a culture of reacting to problems, rather than monitoring and preventing them, meant that some patients receiving surgery were still at an increased risk of receiving unsafe care and treatment.

CQC raised its immediate concerns with the trust's chief executive, requiring the trust to address the urgent safety issue straight away, to give weekly progress reports, and to provide plans showing how it would achieve full compliance with all three standards.

By law, providers of care services have a legal responsibility to make sure they are meeting the essential standards of quality and safety.

On Monday (28 March), the inspection team returned to Derriford Hospital to check that the required improvements had been made, and to observe procedures in eight operating theatres.

Inspectors found that in all the theatres they visited, surgical staff were now using the WHO Surgical Safety Checklist, adapted for England and Wales by the NPSA, which provides a core set of safety checks to improve the safety of surgery by reducing deaths and complications.

Bernadette Hanney, acting Regional Director of CQC in the South West, said that there had been a significant improvement to patient safety.

She said: “Anyone who goes into hospital for an operation is entitled to believe that the clinicians have done all they can to minimise the risk of harm.

“On our first inspection, it was a matter of some concern that even after the series of Never Events at Derriford - and despite the presence of our inspectors – the recognised surgical safety checks were not being carried out properly within some operating theatres.

“Our inspection this week has shown a real improvement. The trust has told us that the surgical safety list is more detailed and is now a mandatory part of the process. Inspectors found that clinical staff appeared to be more aware of the need to avoid serious preventable incidents.

“We are satisfied that Derriford Hospital has now taken this lesson to heart. Use of the surgical safety checklist is essential. There is good evidence that it works and that failure to follow this can lead to serious consequences for patients undergoing surgery.

“The onus is now on the trust to ensure that all its surgical teams continue to carry out the safety checks each and every time. We will continue to monitor the trust to ensure these improvements are sustained and will not hesitate to take action if it becomes necessary.”

Ends

For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232 143.

Notes to editors

• A Never Event is defined as a serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by health care providers.
• The WHO Surgical Safety Checklist, adapted for England and Wales, is for use in any operating theatre environment. It is a tool for the relevant clinical teams to improve the safety of surgery by reducing deaths and complications.