Royal Devon and Exeter Hospital investigates two ‘never event’ errors

Posted: 02/07/2013

It has emerged that two so-called ‘never events’ occurred in a Devon hospital last month.

In one of the events, at the Royal Devon and Exeter Hospital, a patient received a transfusion of the wrong blood type, sources confirmed. The other involved a tube being fed into a patient's heart unnecessarily.

Hospital managers have confirmed they were investigating how the two incidents happened and said providing safe care was their ‘top priority’.

The incidents are categorised by the Department of Health as 'never events’ because they are so serious they should never happen.

Using the wrong blood type in a transfusion can harm or even kill a patient. Possible reactions include an acute haemolytic transfusion reaction (AHTR), when the immune system reacts to the donated blood and begins attacking the blood cells.

The second error was giving a patient an unnecessary angiogram, an invasive test where dye is injected directly into the heart's arteries.

Chief nurse Em Wilkinson-Brice said: "Providing safe care is our top priority. We are currently investigating two incidents and are in touch with both families."

The Care Quality Commission (CQC) confirmed it was aware of the investigations.

NHS England admitted the figure of more than 750 never events in English hospitals over the same period was too high and said it had introduced new measures to ensure patient safety.

The ‘never event’ list was updated for 2012/13 and includes a list of 25 preventable patient safety incidents including:

• wrong site surgery
• retained foreign object post-operation, such as retained swabs or instruments
• wrong route administration of chemotherapy
• suicide using non-collapsible rails
• maternal death due to post-partum haemorrhage after elective caesarean section

Guy Forster, a specialist lawyer in Penningtons’ clinical negligence team, said: “The ‘never events’ list has existed since 2009, yet we are still being contacted time and time again by the victims of wholly avoidable errors, some of which have catastrophic consequences.

“Never events should be just that, events which never occur; all trusts across the country must ensure everything is done to protect the safety of patients and prevent injury where at all possible. It is essential that the Department of Health continues to keep the list under constant review in an effort to stamp out these most basic of hospital mistakes.”

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