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Health Watchdog Gives Derriford Formal Warning
10:43am 10th July 2013
(Updated 10:43am 10th July 2013)
Derriford is told it is failing to protect patients' safety during surgery.
The hospital has been given a formal warning from the Care Quality Commission.
Inspectors went into the Plymouth hospital because of concerns over a series of never events.
They found operation schedules put staff under too much pressure, meaning mistakes could be made.
They were also worried corners were being cut to save time - and nothing was being done to change things.
The Trust's been told to draw up an action plan by Saturday.
Adrian Hughes, regional director of the CQC, said: "Derriford Hospital is a hugely complex organisation dealing with tens of thousands of operations every year from hip implants to brain surgery.
"But that is no excuse for these incidents - which should not happen.
"By definition, any Never Event is a matter of concern. Repeated Never Events suggest a failure to take patient safety seriously enough.
"In this case the hospital had failed to analyse what was happening and take action which would lift the pressure on the operating theatre staff.
"We know that Derriford was under considerable pressure at the time of the inspection. Patients told us that they found the staff considerate and helpful, although often hard pressed.
"Anyone who goes into Derriford for an operation is entitled to know that the hospital has done all it can to minimise the risk of harm.
"While there have been no further Never Events, the trust must now ensure that it takes action to restore public confidence in the safety of its surgery.
"The trust has assured us that it will take action and make the improvements which are now required.
"We will keep a watch on this, and our inspectors will return unannounced in the near future to check that it has made those changes."
Chief Executive at Derriford Hospital Ann James said: "We are a caring hospital with compassionate, committed staff. Patients and visitors see this every day and so did the inspectors. I would like to publicly thank our staff for their incredible work, often in challenging circumstances.
"The warning notice follows never events which happened last year (2012/13). In line with our commitment to openness, the never events were discussed and reported publicly in Board meetings and were the subject of considerable media coverage back in March.
"Since then we have been working hard to ensure that our practices in theatres are as safe as can be and we have not had any further never events (since March 2013).
"Our priority is making sure our patients have the safest, best care available, just as we would want for our own loved ones."
The hospital said in a statement:
"We have taken these steps to improve safety in our theatres and beyond:
* A surgeon is now in charge of theatres, supported by a matron.
* Put in place a full theatre improvement plan led by our new Director of Nursing. This is already leading to changes in practice and culture.
* Sought an independent review to ensure we haven't missed anything.
* Started investing millions of pounds in more nurses, midwives to ensure we get staffing levels right and ease the pressure on our existing staff.
"If you are coming into hospital for an operation here, you are in safe hands:
"Last year (2012/13) nearly 39,000 patients were operated on at Derriford Hospital. We reported eight never events in that year. This should also be put into context. Most hospitals have reported some never events. We are a bigger hospital treating more complex cases than many other hospitals.
"We are in the top decile nationally for incident reporting which is a good indicator of a positive safety culture.
"We have one of the best survival rates in the country - a mortality ratio which is approximately 10% better than expected, making Plymouth the best in the south west and among the best hospital trusts in the country."
You can read the full report here10:43am 10th July 2013
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