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’.
(a don’t stop till you drop production)Home: helpmesortoutstpeters.blogspot.com