Surgical swab left inside patient at Whiston Hospital

Three ‘never events’ – which have the potential to cause serious patient harm or death – occurred at the trust in March, April and May this year.

Never events are defined by the NHS as serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

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St Helens and Knowsley Teaching Hospitals NHS Trust, which runs Whiston Hospital, recorded just one never event in 2019-20, taking place in March.

Two months into the new financial year and this was already eclipsed.

In May, the trust’s executive committee, chaired by chief executive Ann Marr, ordered that the rapid reviews and investigation reports to be presented as soon as they had been completed for each incident.

“There had been three never events, one each in March, April and May, that were extremely concerning,” June’s Trust Board papers said.

“Two related to theatres and the third had taken place in radiology.

“The executive committee asked for a full report of the rapid reviews and investigation reports to be presented as soon as they had been completed for each incident, to ensure that all necessary steps had been taken to identify the root causes and learn lessons.”

None of the patients involved in the never events suffered any serious harm and there is no suggestion they occurred as a result of the coronavirus pandemic.

Little detail has been public on each of the three never events, although some information has been shared in the Trust Board papers.

April’s papers said the never event in March related to a “retained swab during surgery”.

This is when swabs that have been used during surgery are mistakenly left inside the body.

According to May’s papers, the never event in April related to “wrong site administration of nerve block”, which essentially means an anaesthetic injection to block pain was done in the wrong place.

And finally, June’s papers said the never event in May related to the “wrong route administration of medication”, which is where medicine is given but via the incorrect method.

Internal investigations into all three never events have been carried out by the trust as well as a root cause analysis for each incident.

Action plans have been put in place and will be monitored via the trust’s Patient Safety Council and quality committee.

Sue Redfern, the director of nursing, midwifery and governance, presented the findings of the three investigations to the executive committee on June 4.

“The executive committee scrutinised each incident to gain a better understanding of the underlying causes,” it said.

“The action plans were reviewed and it was agreed that additional human factors training should be commissioned to help staff understand the importance of routine checks and challenge when things did not look right.”

Whiston Hospital

The quality committee was also presented a detailed paper on the three never events at its meeting on June 14, where they scrutinised the incidents.

The report outlined the actions being taken following the never events, including human factors training, review of culture, systems and processes.

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Assurances have also been given to St Helens Clinical Commissioning Group (CCG).

The CCG’s governing body papers from July said none of the patients involved in the never events have suffered any serious harm.

It said the deputy chief nurse and the assistant director of safety at St Helens and Knowsley Teaching Hospitals NHS Trust have provided assurance that the events have been taken seriously.