The Care Quality Commission has published the report of an unannounced inspection undertaken in December in response to a series of Never events that had occurred at Royal Devon and Exeter NHS Foundation Trust between May 2015 and December 2017.
Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
The trust had reported seven Never events which met the reporting criteria set by NHS England between May 2015 and December 2017. Two additional serious incidents were under investigation at the time of the inspection.
Of these nine incidents, seven occurred within the surgical division:
Three were in the ophthalmology department
One was in the endoscopy unit
One was in the oral and maxillofacial department
One was in the orthopaedic day surgery
One was within spinal speciality
One was in the critical care unit
The remaining Never event was in maternity.
The full report is available on our website.
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."
“However, we also found that learning from never events was not always shared across specialities. We also found there were some occasions where a patient’s consent was not always gained before the day of surgery in line with recommendations made by the Royal College of Surgeons: Good Surgical Practice."
“We will continue to monitor the trust to check that these improvements are made.”
As this was a focused inspection no ratings were given. The trust rating remains Good as a result of the comprehensive inspection published in February 2016.
Ends
For further information please contact CQC Regional Engagement Officer Lara Orija on 07789 875 306.
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