The Care Quality Commission (CQC) has warned Royal Cornwall Hospital NHS Trust (RCHT) to make improvements to its surgical care services to prevent further ‘never events’ from occurring.
A never event is a serious patient safety incident which is entirely preventable and should not happen if healthcare providers follow national guidance on how to avoid them. Each never event has the potential to cause serious harm or death, though this does not have to happen for an incident to be categorised as a never event.
CQC carried out an announced inspection at short notice in December to see if the trust had taken action following six never events which took place within the surgical care group, and one which took place in the emergency department, between February and October 2020.
Following the inspection, CQC issued a warning notice which required the trust to make significant improvements to the quality of healthcare it provides and to send CQC a report outlining what action it will take to do so.
The trust delivers care from three main sites: Royal Cornwall Hospital in Truro, St. Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance. Inspectors visited all three hospitals, as never events were reported at each.
The inspection in December was carried out in order to assess the trust’s learning and whether changes to practice had taken place in response to the never events.
Due to the targeted nature of the inspections, the rating for surgery remains unchanged.
Amanda Williams, CQC’s Head of Hospital Inspections, said:
“We have told Royal Cornwall Hospital NHS Trust that it must carry out a number of actions in response to the never events to ensure patient safety and to prevent a reoccurrence.
“Although each incident was investigated internally at the time to understand what had gone wrong, and there was some evidence of learning and changes to practices, more still needs to be done.
“We recognise the additional pressures that staff are under as a result of the COVID-19 pandemic, however, never events are extremely serious, and we will continue to monitor the trust closely to ensure that it has taken appropriate action to address these issues and that improvements are made and fully embedded.”
During the inspection, CQC found:
- Governance processes were not effective enough to ensure that changes were made across the trust and staff did not receive adequate training in response to the never events.
- Staff recognised and reported incidents and near misses and managers investigated these, but lessons learned were not shared with the whole team and wider service to ensure patient safety.
- The safety checklist, which should meet World Health Organisation (WHO) standards for surgical procedures, had improved, but the actions required to comply with it had not been managed in a timely way to ensure patient safety.
- Not all relevant audits had been completed, not all staff were aware of the outcomes of audits and learning was not triggered following an audit.
However:
- The service used systems and processes to safely prescribe, administer, record and store medicines.
- When things went wrong, staff apologised and provided patients with information and support.
- Staff felt respected, supported and valued. The service had an open culture where staff felt they could raise concerns.
The Warning Notice issued by CQC required the trust to ensure that staff undergo adequate training in response to the never events by 31 January. By 28 February, it must also improve governance processes to support patient safety across the trust, actions must be taken to mitigate the risk of further never events taking place and relevant audits must be completed.
Royal Cornwall Hospital NHS Trust is rated Requires Improvement overall. Royal Cornwall Hospital is rated Requires Improvement overall and Requires Improvement for surgery. West Cornwall Hospital is rated Good overall but Requires Improvement for surgery. St Michael’s Hospital is rated Good overall and Good for surgery.
Full details of the inspection are given in the reports published online:
Ends
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Full reports for the trust will be published on CQC’s website here.