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Investigation after death at hospital
1:12pm Monday 9th September 2013 in News
AN urgent investigation has been launched into the death of a patient believed to have been given the wrong gas during a procedure at Worcestershire Royal Hospital.
It is not yet known if the error resulted directly in the patient’s death and bosses at Worcestershire Acute Hospitals NHS Trust say they cannot release detailed information about what happened while the investigation is ongoing.
But the trust is treating the incident as a suspected “never event” which, if confirmed, would be its second in less than six months.
Chief medical officer Mark Wake said the trust is currently “reflecting on all the circumstances and evidence available” and that the results of any investigation into a never event would be shared externally as well as with patients, families and carers.
“In the rare and regrettable instances where they do occur, an investigation is immediately undertaken to find the root causes, develop solutions for and then implement them where the incident occurred and more widely if required,” he said.
“This helps to reduce the likelihood of a similar incident re-occurring.”
While the investigation is ongoing, information has been passed to the Worcestershire coroner and organisations including the county’s clinical commissioning groups.
The most recent confirmed “never event” - serious patient safety incidents that should never occur if proper procedure is followed - at Worcestershire Royal took place in April when a patient had the wrong lens inserted during cataract surgery.
The mistake was spotted within minutes of the operation and the patient was taken back into surgery to have the mistake corrected.
An investigation revealed the error was a result of several factors, including the electronic patient record system failing, one of the patients on the surgery list arriving late and the surgeon being “distracted because of personal stress”.
Several changes were made to ensure there is no repeat, including the number of patients on one surgery list being reduced from eight to seven.
Nationally there were 299 never events reported during the last financial year and, starting next month , NHS England plans to publish quarterly lists revealing how many and what type of incidents have occurred at all NHS trusts.
Mike Durkin, NHS England’s director of patient safety, said the change is intended to increase transparency and stimulate greater learning and preventative action.
“Every single never event is one too many,” he said.
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