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Cluster of never events has sparked ‘great deal of soul searching’ says trust CEO


An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures.

The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient.

Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”.

Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events.

She stressed that none of the patients affected had suffered physical harm.

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Source: HSJ, 12 November 2020

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