A HEALTH chief has voiced concern after it emerged two ‘never’ events had been investigated on wards in East Lancashire within weeks of each other.
NHS bosses have admitted that two serious incidents, dubbed ‘never’ events in medical terms as they should never occur, have been probed.
One saw a male patient suffering two broken feet after managing to climb out of a window on a mental health ward at Burnley General Hospital, operated by Lancashire Care NHS Foundation trust.
Cllr Ron O’Keefe, chairman of the health and adults overview and scrutiny committee on Blackburn with Darwen Council, said: “We must be very careful, when we are looking after people with mental health problems, to take every safety precaution possible – he could have been killed.
“It’s the old, old story here of taking precautions after the event, instead of looking for potential problems beforehand.”
Cllr Azhar Ali, executive member for health and wellbeing at Lancashire County Council, said: “Every step should be taken to ensure that patients are safeguarded and I would like to see the trust review their procedures, if they haven’t already.
“Staff there are working very hard, facing a number of challenges, and we should give them all the support we can,” he added.
In the second episode, at the Royal Blackburn Hospital in December, a male patient suffering had a biopsy conducted on the wrong skin lesion.
Cllr O’Keefe and Cllr Ali said that while the Royal Blackburn’s ‘never’ event was a concern, they were confident the East Lancashire hospitals’ board was being "open and transparent", and would learn lessons from the incident.
Speaking about the Pendle View incident, Matthew Joyes, Lancashire Care’s associate director of safety and quality governance, said the patient left a ward last November, via a window, and sustained fracture injuries to his heels.
He added: “Our main priority at the time was to ensure that the patient received the appropriate treatment for his injuries and that he was safe and well following the incident.
“Windows on all of our wards are fitted with restrictors and an investigation was undertaken immediately to ascertain how the person was able to remove it.
“The window was secured straightaway and, while this is an isolated and unique incident, checks were undertaken on a wider scale to reduce the risk of such an incident reoccurring.”
Speaking about the Royal Blackburn event, medical director Dr Damian Riley said: “We have had an issue where a patient attended for a biopsy on a skin lesion, and at the time, the patient has apparently developed a new skin lesion, on which a biopsy was eventually performed.
“We have undertaken a full investigation about how this has occurred, and the whole process surrounding this event, and that will be detailed in a serious case review report.” He confirmed there had been no physical repercussions for the patient from the surgical procedure but the trust wanted to fully establish how the error had been made.