FOI -3461 - Never Events/Sui
FOI -3461 - Never Events/sui
1st April 2013 to 31 March 2014
- All information is provided by financial year as this is how the information is recorded and reported internally and externally
- The total number of serious incidents meeting NHS England StEIS Serious Incidents criteria and reported 1st April 2013 to 31st March 2016 = 30.
- Serious incidents meeting NHS England StEIS Serious Incidents criteria reported from 3 out of 4 Trust sites.
- Total number relating to episode of care which directly or indirectly impacted on patient safety and patient harm = 26 - please see below
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2013/17116 / Not a Never Event / Screening Issues
DRSS screening - IT and communication system failures / No / No / Yes - Screening recall / No
2013/21102 / Not a Never Event / Allegation Against HC Professional
(Patient assaulted) / No / No / No / No
2013/21640 / Not a Never Event / Surgical Error
Sub tenon eye block wrong eye - but surgery not commenced / No / No / Yes - surgery rescheduled / No
2013/24700 / Not a Never Event / Screening Issues
Breast screening programme - equipment malfunction resulting in patient recalls / No / No / Equipment malfunction resulted in patient recalls / No
2013/26857 / Never Event / Drug Incident (general)
Midazolam Never Event / No / No / Naloxone reversal discharged next day / No
2013/27186 / Not a Never Event / Unexpected Death (general)
Death following earlier discharge from A&E / No / No / N/A / N/A
2013/27182 / Not a Never Event / Mat. Services - Unexpected neonatal death
Neonatal sepsis / No / No / N/A / N/A
2013/27755 / Not a Never Event
(de-escalated) / Medical equipment failure
Ceraplug - de-escalated as a Never Event and Serious Incident following NHS England review of investigation report / No / No / No / No
2013/28234 / Not a Never Event / Safeguarding Vulnerable Adult
Collapse CCU investigated as serious fall / No / No / Investigated as serious fall but investigation confirmed medical collapse / No
2013/31511 / Not a Never Event / Pressure ulcer Grade 4
Grade 2 on admission deteriorated to grade 4 / No / No / Yes / No
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question 6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question 7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2013/32142 / Not a Never Event / Unexpected Death (general)
Post- operative (ORIF wrist fracture) / No / No / N/A / No
2013/32704 / Not a Never Event / Unexpected Death (general)
Reported as unexpected death ?cause / No / No - Not unexpected death having investigations for chest infection / N/A / No
2013/37007 / Not a Never Event / Maternity Services - Unexpected neonatal death
6 weeks old BID / No / No / N/A / No
2013/37441 / Not a Never Event / Maternity Services - Unexpected neonatal death
4 days old delayed transfer to tertiary unit / No / No / N/A / No
2014/4 / Not a Never Event / Unexpected Death (general)
Previous visits A&E / No / Yes / N/A / No
2014/1 / Not a Never Event / Accident Whilst in Hospital
Diathermy burn requiring excision of damaged tissue / No / No / Yes - excision of damaged tissue / No
2014/2191 / Not a Never Event / Failure to act on test results
Missed lung cancer / No / No / Yes / No
2014/3446 / Not a Never Event / Ward closure
(D&V outbreak) / No / No / Yes / No
2014/3626 / Never Event / Never Event
Retained gauze swab / No / No / No / No
2014/4228 / Not a Never Event / HAPU Grade 3
Pressure Ulcer Grade 3 / No / No / Yes / No
2014/4638 / Not a Never Event / Unexpected Death (general)
Deterioration and arrest 10 hours post admission / No / Yes / N/A / No
2014/5583 / Not a Never Event / Failure to Act on test Results
Gentamycin Levels / No / No / No / No
2014/7000 / Not a Never Event / HAPU Grade 3
Pressure Ulcer Grade 3 / No / No / Yes / No
2014/7074 / Not a Never Event / HAPU Grade 4
Pressure Ulcer Grade 4 / No / No / Yes / No
2014/7725 / Not a Never Event / Sub-optimal care of the deteriorating patient
Baby born in poor condition, transfer to level 3 NICU / No / No / Yes / No
2014/8561 / Not a Never Event / HAPU Grade 3
Pressure Ulcer Grade 3 / No / No / Yes / No
1st April 2013 to 31 March 2014
- A further 4 serious incidents meeting the NHS England StEIS Serious Incidents criteria reported 1st April 2014 to 31st March 2015 were excluded from the information above as they did not relate to an episode of care which directly or indirectly impacted on patient safety and patient harm. These are provided below for information and completeness of the request
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question 6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question 7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2014/8891 / Not a Never Event / Adverse media coverage or public concern about the organisation or the wider NHS
Wrong letters to wrong relatives – no confidentiality breach. No adverse publicity to date / No / No / No / No
2014/8210 / Not a Never Event / Safeguarding Vulnerable Adult
Concerns re social/domestic care / No / No / No / No
2013/35363
Complaint not an incident / Not a Never Event / Adverse media coverage or public concern about the organisation or the wider NHS
Trust expected PFD at Inquest / No / No / No / No
2013/33179 / Not a Never Event / Fire (accidental)
IT Data Centre and EPR Systems outage / No / No / No / No
1st April 2014 to 31 March 2015
- All information is provided by financial year as this is how the information is recorded and reported internally and externally
- The total number of serious incidents meeting NHS England StEIS Serious Incidents criteria and reported 1st April 2014 to 31st March 2015 = 29.
- Serious incidents meeting NHS England StEIS Serious Incidents criteria reported from 2 out of 4 Trust sites.
- Please note 1 serious incident (2014/35719) was de-escalated following receipt and consideration of Rapid Review by Wigan Borough Clinical Commissioning Group
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question 6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question 7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2015/10570 / Never Event / Surgical Error
Never Event
Wrong site surgery – oral surgery wrong site commenced but not completed / NO / NO / YES - correct site surgery / NO
2015/1039 / Not a Never Event / Pressure Ulcer Grade 3
Grade 3 HAPU / No / No / Yes / No
2015/6842 / Not a Never Event / Ward Closure
D&V outbreak affecting patients and staff / No / No / Yes / No
2015/6471 / Not a Never Event / Ward Closure
D&V outbreak affecting patients and staff / No / No / Yes / No
2015/4765 / Not a Never Event / Other
Alleged assault of patient by non- clinical staff / No / No / No / No
2015/998 / Never Event / Surgical error
Never Event
Retained partial swab identified during return to theatre for laparotomy / No / No / Was removed during laparotomy / No
2014/42438 / Not a Never Event / Safeguarding Vulnerable Adult
Discharged, and died within 12hours / No / No / N/A - patient died / No
2014/42431 / Never Event / Never Event
Retained Gauze swab post cardiology procedure / No / No / Was removed on same day and patient discharged as planned / No
2014/41659 / Not a Never Event / Adverse media coverage or public concern about the organisation or the wider NHS
Patient suffered # femur in collision with absconding patient / Yes / Contributory factor / Yes / Yes - #Femur
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question 6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question 7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2014/41458 / Not a Never Event / Pressure ulcer Grade 3
Grade 3 HAPU / No / No / Yes / No
2014/41235 / Not a Never Event / Safeguarding Vulnerable Child
Lack of internal and external safeguarding notifications / No / No / Yes / No
2014/41125 / Not a Never Event / Ward Closure
D&V outbreak affecting patients and staff / No / No / Yes / No
2014/40265 / Not a Never Event / Serious Self Inflicted Injury by Inpatient
Fall from height resulting in serious multiple injuries / Yes / Yes / Yes / Yes - serious multiple injuries
2014/35719 / Not a Never Event / Pressure ulcer Grade 3
Grade 3 HAPU ICU following BIPAP therapy / De-escalated by CCG following receipt and review of Rapid Review Report. Confirmation of removal from STEIS by NHS England 110315
2014/35593 / Not a Never Event / Surgical Error
Reduced vision following cataract surgery / No / No / Yes / No
2014/35604 / Not a Never Event / Ward Closure
Ward Closure due to CDT / No / No / Yes / No
2014/35588 / Not a Never Event / Maternity Services - Maternal unplanned admission to ITU
Major haemorrhage following C section and post partum haemorrhage / No / No / Yes / No
2014/35292 / Not a Never Event / Communicable Disease and Infection Issue
Patient tested CPE +ive resulting in closure of ward to new admissions / No / No / Yes / No
2014/28947 / Never Event / Never Event
Retained guide pegs post internal fixation / No / No / Yes - removal of guide pegs / No
2014/28149 / Not a Never Event / Allegation against healthcare professional (Assault)Allegation of physical misconduct by 2 members of staff / No / No / No / No
2014/27518 / Not a Never Event / Communicable Disease and Infection Issue
TB / No / No / Yes / No
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question 6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question 7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2014/26574 / Never Event / Never Event
Retained Swab / No / No / Yes - course of anti-biotics / No
2014/23316 / Not a Never Event / Safeguarding Vulnerable Adult
Discharged, re-admitted and died within 24hours / No / No / N/A Patient died / No
2014/23365 / Not a Never Event / Unexpected Death (general)
Patient death following possible Potassium Permanganateingestion. / No / No / No / No
2014/16313 / Never Event / Never Event
Retained foreign object following completion of procedure / No / No / Yes / No
2014/16307 / Not a Never Event / HAPU Grade 3
Pressure Ulcer Grade 3 (was Grade 1 / 2 on admission) / No / No / Yes / No
2014/30451 / Not a Never Event / Screening Issues
Mobile Breast Screening Units Multiple Breakdowns delaying screening dates / No / No / No / No
2014/24827 / Not a Never Event / Adverse media coverage or public concern about the organisation or the wider NHS
241 patients are being invited a review/follow up following concerns raised about their diagnosis and subsequent treatment plan. / No / No / Some yes / No
2014/8210 / Not a Never Event / Safeguarding Vulnerable Adult
Concerns re social/domestic care / No / Yes
But no related WWLFT healthcare concerns - reported as we were receiving hospital / N/A - Patient died / No
1st April 2015 to 31 DECEmber 2015
- All information is provided by financial year as this is how the information is recorded and reported internally and externally
- The total number of serious incidents meeting NHS England StEIS Serious Incidents criteria and reported 1st April 2015 to 31stDecember 2015 =13 .
- Serious incidents meeting NHS England StEIS Serious Incidents criteria reported from 3 out of 4 Trust sites.
- Please note Never Event(2015/35208)relating to Naso-Gastric Tube was de-escalated by NHS England following receipt and review of comprehensive investigation concluded and evidenced this was not the cause of death and that this was tube displacement as opposed to misplacement - Never Event criteria is misplacement
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question 6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question 7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2015/39748 / Not a Never Event / Unexpected/potentially avoidable injury causing serious harm
Grade3/4 Hospital Acquired Pressure Ulcer (HAPU) / No / No / Yes / No
2015/39749 / Not a Never Event / Treatment Delay meeting SI criteria
Unexpected/potentially avoidable death from internal haemorrhage / No / Yes / No / No
2015/36516 / Not a Never Event / Diagnostic Incident including delay meeting SI Criteria
Delayed diagnosis and treatment of gynae.cancer / No / No / No / No
2015/35208 / De-escalated Never
Event / Medical Device Incident meeting SI Criteria -
Never Event
NG Tube displacement / No / No / No / No
2015/35205 / Not a Never Event / Medication Incident Meeting SI Criteria
Anticoagulation administration and prescribing (potentially unavoidable death) / No / No / No / No
2015/34310 / Not a Never Event / Treatment Delay meeting SI criteria
ICU admission following return to theatres (patient death) / No / Yes / Yes / No
2015/32637 / Not a Never Event / Wrong Tooth Extraction
Impacted teeth / No / No / Removal of second impacted tooth / No
2015/32300 / Not a Never Event / Wrong Site Block
Regional anaesthetic block performed to achieve post-operative pain relief / No / No / No / No
Question 1
Record by StEIS log not site / Question 2
Is the Serious Incident a Never Event / Question 3
What did the incident involve
(NHS England StEIS Serious Incident Reporting Criteria) / Question 4
Was the Serious Incident/Never Event as the result of a fall / Question 5
Did the Serious Incident/Never Event result in patient death / Question 6
Did the patient need further medical care and/or surgery as a result of the Serious Incident/Never Event / Question 7
Did the Serious Incident/ Never Event result in the patient breaking or fracturing a bone
2015/27852 / Not a Never Event / Unexpected / potentially avoidable death
Scan incorrectly reported by external service provider / No / No / No / No
2015/25327 / Not a Never Event / Adult Safeguarding
Discharge, Social Care and readmission / No / No / No / No
2015/20622 / Not a Never Event / Diagnostic incident including delay meeting SI criteria (including failure to act on test results)
ICU admission following sigmoidoscopy (patient death) / No / No / No / No
2015/17389 / Not a Never Event / Unexpected death (General)
Unexpected patient death following serious fall and DHS for # neck of femur / No / No / No - secondary factor listed on PM report / No
2015/17388 / Not a Never Event / Pressure Ulcer Grade 3
Grade 3 HAPU / No / No / No / No
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