Never Events: Sheffield hospitals compare well to other NHS trusts for number of avoidable mistakes during treatment

The Never Event incidents were extensively investigated and learned from, members of Sheffield City Council’s health scrutiny sub-committee were assured during a meeting yesterday (June 5). The incidents were referred to in a Sheffield Teaching Hospitals NHS Foundation Trust Quality Account report for 2024-25.

The trust quality director Angie Gibbs said one incident referred to a chest drain being wrongly sited initially on the wrong side of the body, then being corrected. Another involved the wrong site for a pain injection.

Two incidents involved the wrong removal of a patient’s lesions when other lesions were close by. All the mistakes were rectified and learning carried out afterwards, she said.

Committee chair Coun Ruth Milsom, who felt that the press reporting ahead of the meeting had taken the figure out of context, said she had checked out the data going back to 2019-20. The number of incidents each year totalled 9, 3, 6, 8, 4 and then 4 last year.

She said: “We’re always striving for it to be zero but no NHS trust in the country has ever reported zero Never Events. That’s not happened.”

Context

Coun Milsom added that the Sheffield data compares well to other NHS trusts, describing it as “not at all bad” and said there were 13 Never Event incidents at one NHS trust last year.

“These are things we never want to happen but context is important.”

Coun Toby Mallinson said he fully endorsed Coun Milsom’s comments.

Ms Gibbs said the three key priorities last year were the assessment and management of pressure ulcers using a new tool kit, improving the experience of people who are blind and visually impaired and improving the management of acute pain.

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She described the pain management issue as “a big part of patient experience” and said staff had been able to access five-minute training sessions to inform their practice. She said that a patient survey showed that many received the pain relief they felt they needed within 30 minutes or an hour.

A new integrated pain group is looking at the acute, chronic and palliative care aspects of the issue.

Amazing

Ms Gibbs said Sheffield Royal Society for the Blind had been “absolutely amazing in supporting us in that work”. Coun Milsom commented that the RSB told her it had been “absolutely thrilled” to take part.

She added that Disability Sheffield had raised the issue of disabled parking at the hospitals and Ms Gibbs promised to mention it to the trust’s estates department.

This year’s quality improvement priorities are to prevent ‘deconditioning’ of older, frail patients who are admitted to hospital, helping them to stay more active to help prevent falls and other problems, to improve system-based learning following near miss and low-harm incidents and improving healthcare services for young people, including managing their transition to adult services.

Ms Gibbs said that Sheffield has improved its ranking in the national maternity survey, reaching 11th place. “That’s a really good improvement. How people find a service is so important, so we’re really pleased with that result.”

She added that the trust is engaged with a “wealth of research”, including looking at health inequalities. Coun Toby Mallinson said he was really pleased to hear that and the committee will discuss it next year.

Coun Steve Ayris asked what difference the government decision to abolish NHS England and take its functions into the Department of Health and Social Care would make.

Vacancy

Ms Gibbs replied: “I don’t think it will affect the objectives we’ve set because we will continue to drive those forward, regardless of what’s happening nationally.”

Coun Mary Lea asked about the practical steps being taken to help frail patients. She wanted to know whether staff on busy hospital wards would have the time to help patients get up and dressed and ensure they could go to the toilet independently or with help from staff, for example.

Deputy chief nurse Elaine Coghill replied: “Our vacancy position is really good, we’ve got minimal vacancies. The wards in terms of staff are in a very positive position.” She added that nurse directors are working with teams to decide about best practice.

Ms Coghill said that serving elderly patients decaffeinated drinks means they need to go to the toilet less, thus preventing the incidence of falls. (According a report in the Nursing Times last year, that is because caffeine is a mild diuretic which stimulates the bladder).

Coun Laura McClean asked about the number of complaints, which have increased from 2023-24. Ms Gibbs replied that, whereas it is bad if people are unhappy, she was pleased they had taken the time to raise issues, so that they can then be addressed.

She said the main concerns and complaints raised involve long waiting times for treatment and the trust is continuing to work to bring them down.

Challenging

Coun Milsom asked about rising legal costs relating to cases brought against the trust.

Ms Gibbs responded: “Of course we don’t want to see them and always focus on detailed investigations we can do to lower the risk further.”

She added: “It is always challenging, the amount to pay for legal premiums. I would rather spend that on frontline staff, to be fair. If we have harmed someone, I don’t begrudge them getting suitable recompense for that harm but it’s always a drain on resources with legal costs.”

Coun Milsom also asked about infection control plans, particularly over the winter. Ms Coghill said the trust has a “robust action plan” for the management of flu, norovirus and C difficile. That includes ‘decanting’ wards patients from wards temporarily, so that deep cleaning can take place.