FOIA 2544 Request re Never Events
2011/12 &2012/13
Date of
Incident
February 2012
Sex of
Patient
Female
Description of Incident
Harm to
Patient
No harm
Retained swab following forceps delivery.
Titles of Staff Involved





Midwife
Obstetric ST 7
Anaesthetist
Midwifery support
worker
Theatre nurse
Disciplinary
Action
None
Recommendations:

To ensure that staff are adhering to the policies and guidelines, in particular ‘accounting for swabs, packs, sharps and instruments during sterile
procedures’ and ‘guideline for the management of perineal trauma’, he obstetric and gynaecology should conduct observational audit review of the
process for approving swab counts, in the form of ‘spot checks’, and take appropriate action if improvement is required.

The obstetric and gynaecology directorate should develop a system for checking compliance with the ‘accounting for swabs, packs, sharps and
instruments during sterile procedures’, and ‘guideline for the management of perineal trauma policy. This system should be audited.

The maternity governance team should work with the patient safety team to incorporate and reinforce the use of a robust communication system,
such as SBAR, to improve the handover of care between delivery suite theatre and the SBAR process. This can be integrated into safety briefings at
the changeover of shifts for all members of the multidisciplinary team.

The obstetric and gynaecology directorate should ensure that the staff involved are supported and managed according to Trust policy with the
assistance of the NPSA decision tree.

Reinforce the requirement to only enter information onto clinical data systems when personally logged in and to log out when complete.

The theatre and obstetric and gynaecology directorates should use terminology consistent with theatres, for the sizes of swabs commonly used in the
Trust.

The obstetric and gynaecology directorate should provide reassurance to Group 5 with regular updates of the progress of actions.
1
Date of
Incident

Sex of
Patient
Description of Incident
Harm to
Patient
Titles of Staff Involved
Disciplinary
Action
Patient should be invited to meet with the investigation team to share the findings of this report.
June 2011
Male
Elective orthopaedic surgery; incorrect sized insert (one part of
a complete knee prosthesis) used,
Required
further
operation
to correct





Orthopaedic consultant
Orthopaedic registrar x
2
Theatre Health Care
Assistant
Theatre Sister
Scrub nurse
None
Recommendations:
 To facilitate clear communication of the implants required, the exact sizes of the components to be used in knee replacement procedures should be
written on the whiteboard in theatre. A tick should be put when the actual components have been given. This extra precaution is already
implemented.

The trauma and orthopaedic directorate and theatre directorate should use this incident as a case study to stress the importance of active
contribution during all checking processes by all concerned. This information should be re-emphasized in all relevant professional meetings.

The management of breaks for members of the theatre staff, with the aim of minimizing changes of staff members during operations should be
reviewed. This review should included a review of the process for handover.

The trauma and orthopaedic directorate should develop a robust checking system and implement its use across the trust. All relevant staff should be
made aware of this process and once implemented, the system should be audited.

The surgical and theatre directorates should jointly review the process for safe implantation of prostheses. All relevant staff should be made aware of
this process and once implemented, the process should be audited.

The staff involved in this incident should be supported and managed according to Trust policy with the support of the NPSA incident decision tree and
supporting staff policy.

The training, supervision and continuing professional development of theatre staff will be informed by the outcome of this investigation.

The components manufacturers will be informed of this incident to see if the format of implant labels can be reviewed to facilitate easy selection of
compatible implants.
2
Date of
Sex of
Description of Incident
Harm to
Incident
Patient
Patient
September
Female
Following normal vaginal delivery patient required vaginal and
No harm
2011
perineal suturing. Retained swab following this procedure.
Recommendations:
 The obstetric department should source delivery packs that only contain medium gauze swabs.
Titles of Staff Involved


Midwife x 2
Obstetric registrar
Disciplinary
Action
None

The obstetric department should review their induction process to ensure that guidance on the use of swabs during perineal tear is routinely included
at medical staff induction.

The obstetric department should ensure that all midwives and doctors are educated in the correct size of gauze swab to use and the correct
procedure for counting swabs and documentation. This should include a reminder that every gauze swab in a pack, including those in an unopened
bundle, must be counted, even if not used in a procedure.

The obstetric department should review staff awareness of the correct procedure for swab counts for perineal repair.

The obstetric department should ensure that all midwives and doctors are advised to dispose of all gauze swabs after a delivery before opening a
new delivery pack to undertake perineal repair.

The obstetric department should share this report’s findings with the individual doctor and midwives.

The obstetric department should share this report’s findings with the patient.

The obstetric department should liaise with WMPI to suggest they review their birth notes to incorporate a swab count check prior to and after the
birth of the baby.
June 2011
Male
During routine cataract surgery patient had incorrect strength
lens inserted.
No harm



Ophthalmologist
Scrub nurse
Health Care Assistant
None
Recommendations:
 Ensure that the medical records contain the biometry and medisoft printouts the day prior to the operation and agree a process for cancelling surgery
in the event of biometry not being available.

To implement a single process across the Trust for identifying and confirming the IOL power prior to insertion, and to standardise the biometry print
out used across the Trust.

To review the use of surgery checklists used in cataract surgery and consider the use of cataract specific documentation, using this case to raise
3
Date of
Sex of
Incident
Patient
awareness of change in practice.
Description of Incident
Harm to
Patient
Titles of Staff Involved
Disciplinary
Action

To present this report to the Theatre directorate, the ophthalmology directorate and Group 2 and 3 quality and safety committees.

Staff involved in this incident should be supported and managed according to Trust policy with the support of the NPSA incident decision tree.
July 2011
Male
During routine cataract surgery patient had incorrect strength
lens inserted.
No harm


Ophthalmologist
Theatre nurse
None
Recommendations:
 To implement a single process across the Trust for identifying and confirming the IOL power prior to insertion, and to standardise the biometry print
out used across the Trust.

To review the use of surgery checklists used in cataract surgery and consider the use of cataract specific documentation, using this case to raise
awareness of change in practice.

To present this report to the Theatre directorate, the ophthalmology directorate and Group 2 and 3 quality and safety committees.

Staff involved in this incident should be supported and managed according to Trust policy with the support of the NPSA incident decision tree.
June 2011
Male
During right patella resurfacing surgery, a small screw from a
surgical instrument fell off. It could not be found. The patient
was x-rayed in recovery and taken back to theatre for removal
of screw.
Further
operation
to
remove.





Orthopaedic registrar
Orthopaedic consultant
Anaesthetist
Scrub practitioner
Theatre sister
None
Recommendations:
 The ‘policy for the accounting of swabs, sharps and instruments during sterile procedures’ will be reviewed in light of this incident and will be formally
approved and implemented.

Development of a system to more proactively identify, assess and manage ageing theatre equipment should be considered.

The theatre directorate will work with staff to ensure that they understand and are able to undertake their roles and responsibilities to challenge
unsafe practice and escalate patient safety concerns.

The theatre directorate will use this incident to revisit and illustrate the purpose and importance of the WHO checklist.
4
Date of
Sex of
Description of Incident
Harm to
Titles of Staff Involved
Disciplinary
Incident
Patient
Patient
Action
 This report will be presented to the Theatre directorate, the Trauma and Orthopaedic directorate and Group 2 and quality and safety committees.

Staff involved in this incident should be supported and managed according to Trust policy with the support of the NPSA incident decision tree.
June 2012
Female
Methotrexate incorrectly prescribed and administered with the
patient receiving a lower dose than normal on 4 days rather
than as a weekly dose
No harm






Trauma & Orthopaedic
consultant
Trauma & Orthopaedic
SHO x 2
Staff nurse x 3
Medical SHO
Medical registrar
Pharmacist
None
Recommendations:
Anticoagulation
 All patients admitted for emergency or urgent surgery who are on warfarin should be discussed with the haematology doctor on call for advice on
peri-operative management of anticoagulation as patient’s risk of acute thrombotic events is frequently overstated.

All junior and senior medical staff should be reminded of the need for daily INR measurement when using the Fennerty formula for rapid
commencement of oral anticoagulation . This method should only be used in acute VTE’s and very high risk peri-operative anticoagulation
management.

The Trust should undertake a review of current practice regarding anticoagulation prescribing. Following this review the Trust should consider
developing a protocol for anticoagulation prescribing which would strengthen and support safer prescribing and administration of anticoagulation
therapy.
October 2012
Female
Following forceps delivery and episiotomy patient required
suture repair. Tampon retained following this procedure.
No harm


Midwife x 3
Obstetric registrar
None
Recommendations:
 The obstetric and gynaecology directorate should raise awareness of the importance of accurate documentation both on paper and electronically
using this investigation as an example case study.

The obstetric and gynaecology directorate should consider introducing the use of perineal suturing sets [containing all required instruments/swabs
and tampons] to minimise the number of times a midwife is required to leave the room to collect equipment.

In the interim, the obstetric and gynaecology department should raise further awareness of the importance of counting and documenting the tampon
5
Date of
Sex of
Description of Incident
Incident
Patient
count as well as the swabs during a perineal repair.
Harm to
Patient
Titles of Staff Involved
Disciplinary
Action

The obstetric and gynaecology directorate should ensure that staff involved are supported and managed and de-briefed according to trust policy with
the assistance of the NPSA decision tree.

The obstetric and gynaecology directorate should review the induction and updating process for locum doctors, currently there is just a brief verbal
handover.

The obstetric and gynaecology directorate should share this report with the individual staff involved and with the patient.

The obstetric and gynaecology directorate should provide reassurance that the recommendations from this report have been considered. Action plan
progress should be monitored by the division’s Quality and Safety Committee.
January 2012
Female
Wrong site surgery – left adrenalectomy performed rather than
right adrenalectomy.
Patient
remains
under
Trust care
for
ongoing
managem
ent






Consultant
diabetes/endocrinology
Radiologist
Consultant surgeon
Staff nurse
Consultant anaesthetist
Specialist registrar
surgery
None
Recommendations
 The side of any abnormality must be explicitly stated in all radiology reports and a regular audit should be undertaken and acted upon.

The radiology directorate and consultant radiologists will discuss and consider an appropriate way of ensuring that they minimise interruptions when
radiology reports are reviewed and reported on to avoid distractions.

Staff should be reminded to follow the Trust booking process to ensure that the side of the operation is included on the form. This process will be
audited.

Pre-operative assessment clinic will inform the surgeon at the time of the pre-operative visit if there is a lack of clarity about which side the operation
is to be undertaken.

Theatre staff and surgeons will be reminded of the importance of adhering to the surgical safety checklist, with the mandatory displaying of
6
Date of
Sex of
Description of Incident
Incident
Patient
radiological images in theatre at time of surgery, if applicable.
Harm to
Patient
Titles of Staff Involved
Disciplinary
Action

The HEFT surgical safety checklist should be reviewed and amended to include box options of ‘yes’, ‘no’ and ‘not applicable’ answers to the
questions on the form for clarity.

The theatre directorate will continue to audit the use and completion of the surgical safety checklist on a regular basis.

Patient will be invited to meet with the investigation team to discuss this investigation report.

Staff involved in the incident will be debriefed on the findings and recommendations of this report.
7