As reported by the BBC, the Care Quality Commission has issued a warning notice to Royal Cornwall Hospital NHS Trust regarding its surgical practices following a recent short-notice inspection .

Seven ‘never events’ took place in the Trust between February and October last year, triggering the inspection.

Inspectors found that more needed to be done to ensure that learning took place following such events and that any learning be effectively shared. Improvements were found to be necessary to ensure that such events did not happen again.

A ‘never event’ is an occurrence in healthcare which should, simply, never happen. They include a wide range of scenarios such as the incorrect administration of medication to an incorrect surgical procedure or one that is carried out to the wrong part of the body or the wrong patient. It also includes the situation where a piece of surgical equipment such as a guide wire is accidentally left in the patient following a surgical procedure.

According to the CQC report, ‘staff recognised and reported incidents and near misses and managers investigated these, but lessons learned were not shared with the whole team and wider service to ensure patient safety’.

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