Imperial College Healthcare NHS Trust apologised to the patient, who came to no harm
A patient at Charing Cross Hospital had an “invasive line” incorrectly inserted during an operation in May, new papers have revealed.
The patient came to no harm as a result though the incident was flagged by the hospital as a “never event”, meaning it is something its processes should prevent. A spokesperson for Imperial College Healthcare NHS Trust, which runs Charing Cross in Hammersmith, said they apologised to the patient and have introduced further safeguards.
The incident was included in the latest papers published ahead of this week’s North West London Acute Provider Group (NWL APG) Board in Common meeting.
The APG is made up of four NHS Trusts: Imperial, Chelsea and Westminster, London North West University, and The Hillingdon Hospitals.
It is intended to strengthen decision-making across the patch, with the Trusts collectively running 12 hospitals, employing 33,000 staff and serving a population of around 2.2 million people.
The Board papers provide updates on the APG’s progress in recent months, from its finances to ways in which the Trusts have responded to national reports and inquiries.
Details are also given demonstrating compliance, or otherwise, with a range of metrics, from discharge performance to sickness absence. At several points in the papers there are references to a “never event” at Charing Cross Hospital which occurred in May.
One of these reads: “Imperial College Healthcare NHS Trust escalated two incidents highlighting concerns regarding invasive line care and insertion (a never event and a MRSA bloodstream infection) with actions underway to reinforce infection prevention and control standards and use of the central line insertion checklist.”
The Local Democracy Reporting Service (LDRS) asked where the line was inserted though this was not confirmed. It’s also unclear if the invasive line was inserted when it wasn’t needed at all, or whether it was inserted in the incorrect way.
Asked about the incident, a spokesperson for Imperial College Healthcare NHS Trust said: “We systematically gather, analyse and publish data on patient safety incidents, and our latest board papers include details of an incident from May involving the incorrect insertion of an invasive line which met specific criteria to be declared as a ‘never event’ – something that our processes should prevent.
“We apologised to the patient, who thankfully did not come to harm as a result of the incident. We investigated the causes and introduced additional safeguards, including through a patient safety alert to all staff via our Intranet. We are now carrying out a further, multi-disciplinary team review to ensure all local procedural safety checklists are as effective as they can be.”
The report further revealed that, as of May, the APG was failing to meet its deficit plan, missing its target by £7.8m.
This was primarily due to the impact of the resident doctors’ strike in April and “under delivery” against its year-to-date efficiency plan.
Key areas of improvements were however also highlighted, including reductions in long waits, progress against diagnostic recovery plans, and strong performance in various measures related to cancer treatment.
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