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11 patients suffered ‘never events’ at Sheffield Teaching Hospitals

An external investigation commissioned by Sheffield Teaching Hospitals NHS Foundation Trust and the city’s Clinical Commissioning Group has found there to be no ‘systemic safety problem’ despite 11 patients having swabs or dressings left inside them after surgery.

The so called ‘never events’ occurred between 2010 and 2013 and, although no systematic issues were identified by the investigation, there have been 45 recommendations made to reduce the risk of ‘never events’ occurring.

Some of the recommendations include making sure surgeons only use accountable items such as swabs and needles. They also recommend items should be handed to them by a scrub nurse unless a patient’s life is in imminent danger and that all anaesthetists receive further training on swab checks.

The commission’s report, written by patient safety expert Professor Brian Toft and Dr Alex Grice, stated: “Regardless of what precautions are taken there is always the possibility that a serious untoward incident could occur.

“Thus the recommendations, when implemented, will reduce the risk of patients experiencing the inadvertent retention of a foreign object following a surgical or invasive procedure at Sheffield Teaching Hospitals.

“However, what they cannot do is guarantee that this type of serious untoward incident will never happen again.”


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