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Never events investigation concerning post-merger departmental safety

The Client

An acute foundation trust, healthcare sector

Challenge

Serious incidents.

Verita were tasked with helping the teaching hospital understand why one of its departments had four ‘never events’ over the course of four months. While the department had carried out individual never event investigations into each of the incidents the department wanted to understand if there was an underlying systemic cause of the incidents and whether action was needed to be taken to safeguard patients. Our challenge was to identify the cause of the never events, whether there were any recurring themes, and provide recommendations on what could be done to safeguard patients and prevent the never events from happening again.

Scope

Verita were commissioned to conduct an independent review of the department in question. Our remit was to examine the department’s systems and processes to identify any areas of vulnerability as well as notable good practice.

Process

Our team conducted semi-structured interviews and a documentary review. Partner Derek Mechen, director Amber Sargent and associate director Stephanie Bown.

Findings

Although each of the four never events were investigated thoroughly and detailed action plans were drawn up to prevent any recurrence, we found varying levels of willingness to introduce new patient safety measures in the department. This was symptomatic of a more fundamental issue; the department was a single unit in name only. It had recently acquired services from two other hospitals and it lacked a cohesive vision. We found that practices and processes varied considerably across the three sites and that the clinical leadership structure was weak and fragmented.

Recommendations

Our team recommended that the trust set out a strategy for developing an effective, unified department. We also recommended the introduction of a new clinical leadership structure which we designed to raise standards of quality and to move the service forward after this sensitive period.

Outcome

Our report gave the client an independent view on the effectiveness and safety of the service. This was particularly beneficial ahead of a CQC inspection as the division was able to demonstrate that they had taken recent concerns seriously, had immediately addressed areas which could impact on patient safety and had a longer term plan to address areas of weakness.

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