Trust ‘could have avoided four never events’ if it had acted on alert

A trust which had four ‘never events’ where patients were connected to air rather than an oxygen supply could have avoided them if it had been more proactive when a national patient safety alert was sent out several years earlier, a report has found.

In one case, a baby being investigated for sepsis had oxygen saturation levels of just 75% before the mistake was realised. In another, a woman with COPD and pneumonia had oxygen saturation at 80% when she was connected to the air outlet.

Calderdale and Huddersfield Foundation Trust asked the Royal College of Physicians to carry out an invited review after the four never events at Calderdale Royal Hospital in 2018 and 2019. The earliest incident happened in February 2018 but was not identified until a retrospective audit nearly a year later.

The RCP’s report said that, had this been identified earlier, “steps could have been put in place to avoid such incidents from subsequently occurring”.

But it added: “All four never events could have been avoided if the trust had responded more proactively to the previous NHS Improvement patient safety alert about the dangers of erroneously connecting patients to air instead of oxygen and had subsequently restricted access to air outlets.”

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Source: HSJ, 2 November 2020