Homerton Hospital ‘never events’, Hackney: Errors made in gastric tube, contraceptive and kidney procedures

Three ‘never events’ were recorded at a Homerton Hospital in eight months, including during kidney stones and gastric tube.

Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations” - and according to NHS data, three were recorded between April and November 2022.

In one incident, a hormonal coil was used instead of a non-hormonal coil, while on another occasion a naso-gastric tube was incorrectly sited in the right bronchus and medication was administered.

Another patient was listed for a right-sided ureteroscopy and stent - a kidney stones procedure - but it was instead performed on the left side.

Homerton Hospital has an overall ‘outstanding’ rating from the Care Quality Commission (CQC).

The incidents were revealed following freedom of information requests to NHS hospital trusts across the country by medical negligence firm Blackwater Law.

In January NHS England published the number of never events at each trust in the country occurring between April 1 and November 30, 2022.

A spokesperson for Homerton Healthcare NHS Foundation Trust said: “The safety of our patients is our number one priority and we ensure our staff are appropriately trained and supported to offer the best possible care.

“Despite this, unfortunately incidents do occur and we would like to apologise to the patients and the families affected. Each event is fully investigated and reported to the appropriate authorities.

“We review in detail what went wrong and if appropriate introduce protocols and procedures to ensure the learning is shared and embedded to prevent future incidents.”

Jason Brady, partner and head of Blackwater Law, said: “It is concerning to see the details of these ‘never events’.

“At Blackwater Law we see the impact that these incidents have, not just on the person affected, but also on their families.”