Two never events are investigated in Royal Devon and Exeter Hospital
Posted: July 5, 2013
Posted in: Medical Negligence
What the Department of Health calls “never events” have occurred twice in a hospital in Devon last month. One of the said ‘events’ involved a blood transfusion of the wrong blood type, and the other comprised an unneeded angiogram – whereby a tube is fed into the patient’s heart. Both of these uncontrolled, and particularly invasive, procedures have caused a lot of questions to be asked regarding the safety of the Royal Devon and Exeter Hospital’s service. Hospital managers have confirmed that they are currently investigating the reasoning behind these fatal errors.
“Never events are always a matter of concern”
A blood transfusion of the wrong blood type can very severely harm, or even kill, a patient. One possible reaction to such an occurrence is an acute haemolytic transfusion reaction (AHTR), whereby the immune system recognises the donated blood and begins to attack the blood cells.
The other ‘never event’ was a patient receiving an unneeded angiogram. This is a very invasive test where dye is injected directly into the heart’s arteries.
Both families are in contact with medical staff.
The Care Quality Commission (CQC) confirmed that it was aware of the investigation and will take the results into account at its next inspection. A spokeman said: “Never events are by definition always a matter of concern and it is important that there is an investigation and any lessons are learned so there is not a recurrence.“
BBC research suggests that there have been six ‘never events’ at the Royal Devon and Exeter NHS Trust between 2009 and 2012. The frequency of such events is being investigated across England, with NHS England admitting the figures to be too high. NHS England says that they have introduced new measures to better ensure patient safety.
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