“The term ‘never event’ was first introduced in 2001 in reference to particularly shocking medical errors that should never occur.” … Care Quality Commission

In 2007, I made a report to Morecambe Bay Trust management that a patient had been injured by inappropriate insertion of a naso-gastric feeding tube which had resulted in ‘Aspiration Pneumonia’ or feed being pumped into the lung(s). Misplaced naso-gastric tubes are listed as ‘never events’ because they ought never to happen. The patient died 10 days later. The Death Certificate did not blame the never-event; as though it had never happened. When the Trust failed to initiate any investigation of the incident, I resigned my post as Staff Nurse citing Trust failure to prioritise patient safety.

Four years later, I read, the Trust was responsible for the death of another patient by the same means:

NORTH-WEST EVENING MAIL Thursday, 20 February 2014

Hospital patient had feeding tube in lung A HOSPITAL patient died days after a wrongly placed feeding tube was found in their lung. The catastrophic error was one of nine “never events” – mistakes so bad they should never have taken place – recorded at the University Hospitals of Morecambe Bay NHS Foundation Trust during the three-year period spanning 2011, 2012 and 2013. UHMBT faced a clinical negligence claim for one of the events, the misplacement of a naso-gastric feeding tube at its Royal Lancaster Infirmary site in 2011. Confirming details of the incident the Trust said: “The patient had an NG tube in situ and had been fed through this tube and feeds had been running for four hours in total. The patient experienced right-sided chest pain and an urgent chest x-ray showed the NG tube in the right lung. The patient died two days later.”

“We take these events extremely seriously, investigate them thoroughly and ensure that we share learning from each to minimise any re-occurrence of a similar event.“

“The safety of our patients is our priority and we actively encourage members of staff to report any events which take place where they have concerns that patient care may have been compromised.”

Plus ca change, plus c’est la meme chose…

Now please recall that, in 2007, the Trust had failed to investigate an identical event. When I took out a Formal Grievance in 2008, on that very subject, the Trust admitted the failure, but again failed to initiate any investigation. Imagine then my surprise, to read that the Trust Press Responses to inquiries from both a national and a local newspaper assured readers that “The Trust did carry out investigations into many of these concerns, in 2008…”