Now, let’s have a look at some of the disturbing stuff:
“The
Integrated Governance and Assurance Committee minutes
2013 Any
Other Business
1. The
Chief Nurse reported a Never Event, which was currently subject to
investigations. The patient had since passed away, but IGAC was assured that
the event did not contribute to the patient’s death.”
I should explain what a ‘Never Event’ is – it’s a mistake
that NHS England has decided should never happen and hospitals are required to
report on them.
These aren’t just everyday mistakes – those happen and can be
very serious. These are mistakes that should ‘never’ happen like;
Putting feeding
tubes down into the lungs instead
of the stomach.
Giving the wrong
or no insulin.
Operating on the
wrong thing.
Operating on the
wrong person (no, really).
Letting patients
fall out of windows.
Leaving foreign
objects in peoples bodies after operations.
And so on – you get the idea. These mistakes usually mean a death
which is completely avoidable and should ‘never happen’.
Mind you, one class of incident is where prisoners in custody
escape from the hospital. Keeping people locked up is not a hospital’s
responsibility, it’s not about treatment and really – as far as the patient is
concerned - it is quite a good ‘outcome’.
The BBC recently published all the ‘Never Event’ statistics
and I republished them so you could look up any Trust.
They are on my other Blog (the really serious one);
helpmesortoutthenhs.blogspot.com
Here are the figures for 2009/12:
Ashford & St Peter's Hospitals NHS FoundationTrust 5
Retained
foreign object post-operation 3
Wrong site
surgery 1
Maladministration
of Insulin 1
That’s 5 in 4 years, so another one is quite a serious
matter, not just ‘any other business’.
Neil Harris
(a don’t stop till you drop production)
Home:
helpmesortoutstpeters.blogspot.comContact: neilwithpromisestokeep@gmail.com
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