Trust warned by regulator after cluster of never events

The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months.

The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year.

In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initiated as part of the special measures regime.

The inspectors visited three of the trust’s sites where the never events had happened. These were: Royal Cornwall Hospital in Truro, St Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance.

The inspectors reported that governance processes were “not effective enough” to ensure that changes were made across the trust, and that lessons from incidents and near misses were “not shared with the whole team and wider service to ensure patient safety”.

Their report also stated the trust’s safety checklist for surgical procedures had improved but was not fully compliant with the World Health Organisation’s standards.

However, the CQC found staff apologised and provided patients with information when things had gone wrong, and that there was an open culture in which staff felt able to raise concerns.

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Source: HSJ, 17 February 2021