‘Never event’ highlights safety concerns after suture needle left inside patient at Stevenage’s Lister Hospital

A piece of surgical equipment was left inside a patient following an operation at Stevenage’s Lister Hospital, highlighting potential weaknesses in how the organisation manages fundamental safety processes.

The serious incident happened in the hospital’s maternity unit, when a suture needle – used to stitch an open wound closed – was left inside a patient.

It has been recorded as a ‘never event’, which means it had the potential to cause serious harm, or even death.

It is deemed by the NHS to be a “largely preventable safety incident that should not occur if existing national guidance or safety recommendations have been implemented by the healthcare provider”.

The foreword to the Never Events Policy and Framework states: “Never events are key indicators that there have been failures to put in place the required systemic barriers to error and their occurrence can tell commissioners something fundamental about the quality, care and safety processes in an organisation.”

‘Never events’ are different from other serious incidents as the overriding principle of having the ‘never events’ list is that even a single ‘never event’ acts as a red flag that an organisation’s systems for implementing existing safety advice or alerts might not be robust.

Between April 2016 and March 2017, the East and North Herts NHS Trust, which runs Lister, recorded another ‘never event’, this time involving a wrong implant or prosthesis that was put in a patient.

The latest ‘never event’, concerning the retained suture needle at Lister, happened sometime between April and June this year and was one of 107 ‘never events’ reported by NHS trusts across the country during that time period.

Nationally, 30 of these ‘never events’ involved retaining a foreign object post procedure, 38 were due to wrong site surgery and 18 involved a wrong implant or prosthesis.

A spokesman for the East and North Herts NHS Trust said: “The ‘never event’ happened at the Lister’s maternity unit in 2017 and was the result of a retained small suture needle. No harm to the patient occurred.”

The spokesman said they were limited in what they could say because the patient did not want to be identified.