Doncaster hospital records 'never event' after doctors leave wire inside patient

In documents published to the hospital trust board of directors, it was reported in December 2016 a ‘retained wire’ was left inside a patient. An investigation was subsequently launched.

A never events is defined as ‘adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability.’

The report said the never event was now subject to the ‘Serious Incident’ process.

The patient in question was told about the error and received extra care and procudures following the discovery of the medical mishap.

The Trust said it had been ‘open and transparent’ and NHS Doncaster CCG has been alerted to the error and added it was keen to learn the lessons in order to improve further safeguarding techniques in future.

Suzannah Cookson, deputy chief nurse and designated nurse for children is said to be involved in the Root Cause Analysis.

Mr Sewa Singh, medical director at DBTH, said: “If a ‘serious incident’ or ‘never event’ occurs at the Trust, we carry out a detailed and comprehensive investigation, sharing the outcomes with the patient or family concerned.

“Resulting recommendations are designed to reduce the risk of recurrence, taking action in the relevant services and sharing learning across the organisation as well as with the wider NHS when appropriate, in order that lessons are learned.

“In this instance, we have apologised to the patient, who received further care for their underlying condition and subsequent removal of the guide-wire.

“We intend to share the outcome of the investigation with the patient when the report is finalised.

“Following a review, we have identified additional safety measures and training enhancements for local and regional medical staff in this procedure.