Shrewsbury and Telford Hospital NHS Trust investigating a possible never event

An investigation is taking place into a possible never event recorded by Shrewsbury and Telford Hospital NHS Trust in December 2018.

A patient had consented to receive Panretinal Photocoagulation (PRP), a laser treatment, for their left eye.

The patient was prepped and received anaesthetic drops in the correct left eye, ready for the contact lens to be applied. The contact lens focuses the laser onto the retina.

However, the contact lens was placed in the right eye, and a few spots of laser treatment were applied.

At present this is being treated as a never event, although at the conclusion of the investigation, this may be altered.

Never event data for Shrewsbury and Telford Hospital NHS Trust show there were 3 never events recorded for the period of 1st April to 31st December 2018. This included 2 incidents of retained foreign object post procedure.

What is a never event?

Never Events are serious, largely preventable safety incidents that should not occur if the available preventative measures are implemented. They include things like wrong site surgery or foreign objects left in a person’s body after an operation. Whilst they are rare, incidents can have devastating consequences for the patient, their family and the NHS.

As explained by the CQC 

How common are never events?

Jon Ashworth, Shadow Secretary of State for Health, recently asked in a written question to the Department of Health and Social Care, how many recorded incidents were classified as never events each year. This was answered on the 31st January 2019, by Caroline Dinenage, Minister of State, quoting figures from the Strategic Executive Information System (StEIS).

Number of never events graph

Our NHS Tracker collates many sources of NHS data to provide an easy way to view these stats for each trust. View the performance statistics for Shrewsbury and Telford Hospital NHS Trust.

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