Royal Cornwall Hospital NHS Trust told to 'make improvements' after incidents put patients at risk

An NHS Trust in Cornwall has been told to make improvements by the Care Quality Commission (CQC) following a series of incidents which put the safety of patients at risk.

Three hospitals run by the Royal Cornwall Hospital NHS Trust were visited by health watchdogs in December after reports of seven 'never' events earlier in the year.

A never event is a serious patient safety incident which is entirely preventable and should not happen if healthcare providers follow national guidance on how to avoid them.

Each never event has the potential to cause serious harm or even death, though this does not have to happen for an incident to be categorised as a never event.

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

Following the inspection, the CQC issued a warning notice which required the trust to make significant improvements to the quality of healthcare it provides, and to send the CQC a report outlining how it will do it.

Six never events were reported in the surgical care department, with one reported in the emergency department.

Inspectors visited all three of the trust's sites, Royal Cornwall Hospital in Truro, St. Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance, as never events were reported at each.

The inspection in December was carried out in order to assess the trust’s learning and whether changes to practice had taken place in response to the never events.

Due to the targeted nature of the inspections, the rating for surgery remains unchanged.

Amanda Williams, CQC’s Head of Hospital Inspections, said: “We have told Royal Cornwall Hospital NHS Trust that it must carry out a number of actions in response to the never events to ensure patient safety and to prevent a reoccurrence.

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

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

During the inspection, CQC found:

  • Governance processes were not effective enough to ensure that changes were made across the trust and staff did not receive adequate training in response to the never events.

  • Staff recognised and reported incidents and near misses and managers investigated these, but lessons learned were not shared with the whole team and wider service to ensure patient safety.

  • The safety checklist, which should meet World Health Organisation (WHO) standards for surgical procedures, had improved, but the actions required to comply with it had not been managed in a timely way to ensure patient safety.

  • Not all relevant audits had been completed, not all staff were aware of the outcomes of audits and learning was not triggered following an audit.


  • The service used systems and processes to safely prescribe, administer, record and store medicines.

  • When things went wrong, staff apologised and provided patients with information and support.

  • Staff felt respected, supported and valued. The service had an open culture where staff felt they could raise concerns.

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

By 28 February, it must also improve governance processes to support patient safety across the trust, actions must be taken to mitigate the risk of further never events taking place and relevant audits must be completed.

The Chief Executive of the trust has apologised to patients for the 'shortcomings', adding that work is ongoing to improve the level of care in line with CQC standards.

  • Full statement from RCHT Chief Executive, Kate Shields:

“We apologise to our patients affected for the shortcomings in their care.  A never event is exactly that and should never happen, regardless of the unprecedented times we live in with the challenges they present. We have been open with everyone involved and shared the findings of our investigations along with what we are doing to reduce the risk of anything similar occurring in the future.

“We fully accept the Care Quality Commission’s recommendations.  We have been working hard with teams across our hospitals and are well on the way to making the improvements the CQC requested.

“This has included strengthening our human factors training, which equips our staff with skills to spot potential problems where mistakes could cause harm to our patients.  We are also taking advantage of digital advances to support learning and awareness of ‘never events’ across the organisation.

“Culturally we have already come a long way, with staff who are confident to speak up when things go wrong so that we can learn and improve.  Together we are determined to make our hospitals among the safest in the country.”

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