Medical ‘never event’ during surgery at Shropshire orthopaedic hospital investigated by health bosses
A medical ‘never event’ during surgery at the Robert Jones and Agnes Hunt Orthopaedic Hospital (RJAH) has been investigated by health bosses.
A report to the board of Telford and Wrekin Clinical Commissioning Group (CCG) ahead of a meeting on Tuesday says an action plan was implemented following the incident, which happened in September.
The exact nature of the 'never event' is not known.
The Care Quality Commission describes never events as, “serious, largely preventable safety incidents that should not occur if the available preventative measures are implemented”.
The report to the CCG board says: “A never event was reported in September 2019 relating to surgery and the report has been received by the CCG and shared with NHSE Specialised Commissioning.
“The CCG has returned the investigation report as they have identified a number of further recommendations to be considered by the trust.”
It adds that the CCG was due to visit the hospital in Gobowen last month to “monitor implementation of the action plan”.
The hospital last recorded a ‘never event’ in October 2018.
The CCG will also hear next week that a ‘serious incident’ happened at the RJAH last month in which medication was administered to a patient with a known allergy.
A report to the board says: “A number of measures have been put in place to manage the risks and the investigation is ongoing with monthly updates provided to the CCG on progress.”
The CCG board will meet on Tuesday at Wolverhampton University’s Telford campus in Priorslee. The meeting starts at 1.30pm and is open to the public.
