A patient who died after being given the wrong gas to breathe was one of over 80 serious incidents at Watford General Hospital last year - double the figure from the previous year.
In another incident a stillbirth occurred after doctors had misinterpreted the results of a cardiotocography, and the foetus’ heart rate and movements were not monitored - actions which could have saved its life. ‘Poor documentation’ was also cited.
The deaths are listed in a Serious Incidents 2012/2013 Summary Report as discussed at the July 25 board meeting, when it was revealed 83 serious incidents were recorded last year (compared with just 42 in 2010/11, and 50 the previous year), although last year 28 'serious' pressure ulcers were subsequently downgraded.
The report highlights another serious incident in which a chemotherapy patient had a nasogastric tube misplaced after an x-ray was misinterpreted, and there was a ‘lack of communication from radiology’.
This incident constituted a ‘never event’, which is the term the NHS gives to ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’.
The case of the wrong gas being administered causing death was also classed as a never event.
The report mentions other serious incidents including:
- A neonatal death following ‘poor communication and decision making’ and ‘delays in care for infant’
- A pregnancy complication in which the placenta became detached from the uterus of the mother, after a doctor did not respond to ‘bleeps’ (alarms) for a patient review
- A patient whose Hepatitis B was reactivated after they underwent chemotherapy because it was not routine to check for the virus (reactivation can be fatal). The hospital reviewed its policy to check whether patients have Hepatitis B pre-chemotherapy
- Morphine going ‘missing’
- A ‘near-miss’ in which a patient mistakenly underwent a biopsy (a test) without their identity being checked first
- An allegation of abuse against a healthcare assistant who, it later transpired, had not been CRB-checked
- C. Diff cases involving ‘poor communication’ and the patient not being isolated - nor was the area deep cleaned
- A patient who suffered a fracture from a fall sustained while using a foot pedal to open a bin
Katherine Murphy, chief executive of healthcare charity the Patients Association, said: "As suggested by the name, these sorts of events are utterly unacceptable and pose a huge risk to patient safety and well-being.
"Whilst the Patient Association accepts that accidents will sometimes occur, it is vital that lessons are learnt each time to ensure that they are not repeated.
"This is yet another reminder of the need to properly fund the regulation of healthcare to ensure that it detects patterns of errors such as these, and acts to ensure that no more patients are put at risk."
West Hertfordshire Hospitals NHS Trust’s Medical Director, Dr Mike Van der Watt, said: “We take the safety of our patients very seriously, therefore, incident reports are brought to the trust Board as a way of demonstrating through openness and transparency how we learn from incidents. We have made appropriate apologies to the patients, family and friends involved in these incidents and shared the reports and lessons learnt as appropriate. However, for legal reasons we have to respect patient confidentiality and therefore have to limit the amount of information published. Incidents are also reported to our commissioners and other appropriate bodies.
“Despite wider reporting requirements over the past year, we have not seen a significant increase in the number of serious incidents, which would have been expected. We are required to report every case of pressure ulcers to our commissioners, prior to investigation. The root cause of each incident is thoroughly explored to determine whether appropriate care had been given to the patient in order to prevent an ulcer occurring. For instance, some patients are more vulnerable to pressure ulcers due to their medical condition. Between April 2012 and March 2013, 28 of the 83 pressure ulcers reported by the trust were subsequently downgraded as the patient was found to have received appropriate care and the pressure ulcer considered to be unavoidable.
“Please be assured that we take each incident very seriously and have a very robust plan in place for dealing with them, which includes thorough investigation, followed by an action plan detailing appropriate lessons to be learnt. In addition we would take the necessary action against staff as appropriate, for instance performance management or dismissal.”