CQC warns Plymouth Hospitals NHS Trust that it has failed to protect the safety of patients at Derriford Hospital

10 July 2013

The Care Quality Commission has told Plymouth Hospitals NHS Trust that it must make urgent improvements to protect patients undergoing surgery at Derriford Hospital.

CQC has issued a formal warning to the trust following an unannounced inspection at which it failed to meet five of the nine national standards which were reviewed.

A team of inspectors spent two weeks at the hospital in April following up concerns, including eight Never Events which have been reported in the last year. A full report of this inspection has been published on the CQC website, read the full report here.

In February 2011, the Care Quality Commission had taken action against the trust over similar safety concerns in the operating theatres. At the time, the hospital responded by ensuring that safety check lists, designed to reduce the risk of deaths and complications, were used properly by all surgical teams.

On the latest inspection, CQC inspectors found that the surgical safety checklists were still being used as required. But inspectors also found that the way in which operations were scheduled was putting staff under too much pressure, creating a risk that mistakes would be made.

Clinical staff said that the timetables were unrealistic, and did not make allowance for any unexpected incidents which could cause delays. When the list over ran, staff might cut corners to save time. Staff shortages meant that specialist theatre staff were often not available

Inspectors found that while the trust had identified the same issues, the changes which were needed had not been made. Auditing had not been good enough to prevent further incidents taking place. The hospital had failed to identify and manage the risks to patients.

Adrian Hughes, Regional Director of CQC in the South, said:

“Derriford Hospital is a hugely complex organisation dealing with tens of thousands of operations every year from hip implants to brain surgery.

But that is no excuse for these incidents – which should not happen.

“By definition, any Never Event is a matter of concern. Repeated Never Events suggest a failure to take patient safety seriously enough. In this case the hospital had failed to analyse what was happening and take action which would lift the pressure on the operating theatre staff.

“We know that Derriford was under considerable pressure at the time of the inspection. Patients told us that they found the staff considerate and helpful, although often hard pressed.

“Anyone who goes into Derriford for an operation is entitled to know that the hospital has done all it can to minimise the risk of harm. While there have been no further Never Events, the trust must now ensure that it takes action to restore public confidence in the safety of its surgery.

“The trust has assured us that it will take action and make the improvements which are now required. We will keep a watch on this, and our inspectors will return unannounced in the near future to check that it has made those changes.”

Ends

For further information please contact the CQC press office on 0207 448 9239 or out of hours on 07917 232143.

Notes to editors

Inspectors found that Plymouth Hospitals NHS Trust was failing to meet five standards at Derriford Hospital:

• Respecting and involving people who use services
• Care and welfare of people who use services
• Staffing
• Assessing and monitoring the quality of service provision
• Records

The trust was meeting four standards checked at this inspection:

• Cooperating with other providers
• Management of medicines
• Requirements relating to workers
• Complaints

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.

In April 2011, CQC found that surgical teams at Plymouth Hospitals NHS Trust had taken action to ensure that check-lists recommended by the World Health Organisation (WHO) and the National Patient Safety Agency (NPSA) were being used effectively. The inspection followed six Never events in six months.