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Royal Cornwall Hospital NHS Trust was told to “make improvements” after incidents put patients at risk | Western Country




An NHS Trust in Cornwall has been told to make improvements by the Quality of Care Commission (CQC) following a series of incidents that endanger patient safety.

Three hospitals run by the Royal Cornwall Hospital NHS Trust were visited by health observers in December following reports of seven ‘never’ events earlier this year.

An event is never a serious patient safety incident which is completely preventable and should not occur if health care providers follow national guidelines on how to avoid them.

Every event never has the potential to cause serious harm or even death, although it does not have to happen that an incident is ever categorized as an event.

Between February and October 2020, six of these events occurred within the surgical care group with another occurring in the emergency department.

Following the inspection, the CQC issued a warning notice seeking confidence to make significant improvements in the quality of health care it provides and to send the CQC a report outlining how it would do so.

Six events were not reported to the surgical care department, with one reported to the emergency department.

Inspectors visited the three trust sites, RoyalCornwallH Hospital in Truro, St. Louis Hospital. Michaels at Hayle and WestCornwallH Hospital in Penzance, as no events were ever reported in either.

The December inspection was conducted to assess learning of beliefs and whether changes in practice had ever occurred in response to events.

Due to the intended nature of the inspections, the terat for surgery remains unchanged.

Amanda Williams, Head of Hospital Inspections at CQCs, said: “We have told RoyalCornwallH Hospital NHS Trust that it must take a number of actions in response to events never to ensure patient safety and prevent a recurrence.

Although each incident was investigated internally at the time to understand what had gone wrong, and there was some evidence of learning and changing practices, more still needs to be done.

We recognize the additional pressures that are under staff as a result of the COVID-19 pandemic, however, events are never extremely serious and we will continue to closely monitor the trust to ensure that it has taken appropriate action to address these issues. and that improvements are made and are fully embedded.

During the inspection, CQC found:

  • The safety checklist, which must meet World Health Organization (WHO) standards for surgical procedures, was improved, but the actions required to comply with it were not properly managed to ensure the safety of patient.


The Warning Notice issued by the CQC required trust to ensure that staff undergo proper training in response to events never until January 31st.

By 28 February, it should also improve governance processes to support patient safety across the board, action should be taken to mitigate the risk of further events not occurring, and relevant audits should be completed.

The trust chief executive has apologized to patients for the ‘deficiencies’, adding that work is ongoing to improve the level of care in line with CQC standards.

We apologize to our affected patients for deficiencies in their care. An event is never exactly that and should never happen, despite the unprecedented times we live with the challenges they present. We have been open with everyone involved and have shared the findings of our investigation along with what we are doing to reduce the risk of anything similar happening in the future.

We fully accept the recommendations of the Quality of Care Commission. We have worked hard with teams across our hospitals and are on track to make the improvements CQC requested.

This has included strengthening our human factor training, which equips our staff with the skills to identify potential problems where mistakes can cause harm to our patients. We are also taking advantage of digital advancements to support learning and event-aware awareness across the organization.

Culturally, we have come a long way, with staff who have the confidence to speak up when things go wrong in order to learn and improve. Together we are determined to make our hospitals one of the safest in the country.

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