Charing Cross Hospital in Hammersmith reported a never event in May, where a patient had an invasive line incorrectly inserted during an operation. The incident was disclosed in papers for the North West London Acute Provider Group (NWL APG) Board in Common meeting. The patient came to no harm, and Imperial College Healthcare NHS Trust, which runs the hospital, apologised and implemented additional safeguards.
Details of the Never Event
The incident was flagged as a never event, meaning it should have been prevented by standard processes. The trust escalated two incidents concerning invasive line care and insertion, including a MRSA bloodstream infection. Actions are underway to reinforce infection prevention and control standards and use of the central line insertion checklist. The exact nature of the incorrect insertion—whether the line was not needed or inserted incorrectly—was not specified.
Trust Response and Safeguards
A spokesperson for Imperial College Healthcare NHS Trust said: “We systematically gather, analyse and publish data on patient safety incidents, and our latest board papers include details of an incident from May involving the incorrect insertion of an invasive line which met specific criteria to be declared as a ‘never event’ – something that our processes should prevent. We apologised to the patient, who thankfully did not come to harm as a result of the incident. We investigated the causes and introduced additional safeguards, including through a patient safety alert to all staff via our Intranet. We are now carrying out a further, multi-disciplinary team review to ensure all local procedural safety checklists are as effective as they can be.”
Broader Context of the NWL APG
The NWL APG comprises four NHS Trusts: Imperial, Chelsea and Westminster, London North West University, and The Hillingdon Hospitals. They collectively run 12 hospitals, employ 33,000 staff, and serve approximately 2.2 million people. The board papers also revealed that the APG missed its deficit target by £7.8m as of May, primarily due to the impact of the resident doctors’ strike in April and under delivery against its efficiency plan. However, improvements were noted in reducing long waits, diagnostic recovery, and cancer treatment measures.
