The three serious 'never events' mistakes at West Herts hospitals

In the first incident, in December 2019, ‘a wrong side block’ was given to a patient, and in the second, in January 2020, an epidural was given on the wrong side.

They are two of three so-called ‘never events’ recorded at Watford General and St Albans City Hospital over a 12-month period.

The third incident occurred at Watford General in August 2019, when a nasogastric tube was wrongly inserted.

Watford General Hospital

They are all included in the annual report for serious incidents and never events 2019/20, which was reported to a meeting of the West Herts Hospitals Trust board on October 1.

In addition to the ‘never events' – deemed to be serious preventable incidents that should not happen – the report highlights 21 serious incidents.

And it also highlights the ‘key learning’ from the investigation of the incidents.

As a result, says the report, for example, feeding does not start through a nasogastric tube with a ‘queried’ location until the x-ray has been reviewed by a consultant radiologist.

And a ‘stop before you block’ process, with reminder posters, has also been implemented.

The number of serious incidents recorded in the report is less than half of the 45 serious incidents that were reported in the previous year (2018/19).

Following the meeting, the trust’s chief medical officer Mike van der Watt pointed to the ‘culture of learning’ and to the drop in incidents, compared to the previous year.

He said: "The number of serious incidents and never events at the trust in 2019/20 has decreased by over half compared with 2018/19.

"This significantly lower figure is testament to our culture of learning from patient safety incidents.

"The reports and action plans from every serious incident investigation, which identifies the root cause and contributory factors, are shared with the relevant teams, our commissioners at Herts Valleys Clinical Commissioning Group and with NHS Improvement.

"We monitor action plans through the appropriate clinical governance group and share this with the patient and their family."

A breakdown of the serious incidents in the report this year shows that six related to treatment delay and three to a surgical or invasive procedure.

In the field of maternity and obstetric medicine there were five incidents – three relating to the mother and two to the baby.

In addition two incidents related to a breach of information governance, two to slips, trips or falls, two to a diagnostic incident and one to ‘suboptimal care of a deteriorating patent’.