Patient at Charing Cross Hospital Suffers from Incorrect Insertion of Invasive Line

Recent documents have disclosed that a patient at Charing Cross Hospital experienced an incorrectly inserted “invasive line” during a surgical procedure in May. Fortunately, the patient did not suffer any harm as a result of this incident, which has been classified by the hospital as a “never event.” This designation indicates that such occurrences should be preventable by the institution’s processes. A representative from Imperial College Healthcare NHS Trust, which operates Charing Cross Hospital in Hammersmith, expressed their apologies to the patient and outlined the implementation of additional safeguards to prevent future occurrences.

Overview of the Incident

The incident was highlighted in the latest documentation released prior to the upcoming North West London Acute Provider Group (NWL APG) Board in Common meeting. The APG comprises four NHS Trusts: Imperial, Chelsea and Westminster, London North West University, and The Hillingdon Hospitals. This collaborative effort aims to enhance decision-making across the region, with the Trusts collectively managing 12 hospitals, employing around 33,000 staff, and catering to a population of approximately 2.2 million residents.

The Board papers provide insights into the APG’s recent developments, covering financial updates as well as responses to national reports and inquiries. They also include metrics related to various aspects of hospital performance, such as discharge efficiency and staff sickness rates. Within these documents, several mentions of the “never event” at Charing Cross Hospital are made. One excerpt states that “Imperial College Healthcare NHS Trust escalated two incidents highlighting concerns regarding invasive line care and insertion (a never event and a MRSA bloodstream infection), with actions underway to reinforce infection prevention and control standards and the use of the central line insertion checklist.”

Details of the Investigation

The Local Democracy Reporting Service (LDRS) inquired about the specifics of where the invasive line was inserted; however, this information has not been disclosed. It remains unclear whether the line was inserted unnecessarily or if it was the method of insertion that was incorrect. In response to questions regarding the incident, a spokesperson for Imperial College Healthcare NHS Trust stated, “We systematically gather, analyse, and publish data on patient safety incidents, and our latest board papers include details of an incident from May involving the incorrect insertion of an invasive line which met specific criteria to be declared as a ‘never event’ – something that our processes should prevent.”

They added, “We apologised to the patient, who thankfully did not come to harm as a result of the incident. We investigated the causes and introduced additional safeguards, including a patient safety alert to all staff via our Intranet. We are now carrying out a further, multi-disciplinary team review to ensure all local procedural safety checklists are as effective as they can be.”

Financial Implications and Performance Highlights

Furthermore, the report indicated that as of May, the APG was not meeting its financial deficit reduction plan, falling short by £7.8 million. This shortfall has been attributed largely to the impact of the resident doctors’ strike in April, along with “under delivery” against its year-to-date efficiency targets. Nevertheless, the report also highlighted key areas of progress, such as reductions in lengthy patient waits, advancements in diagnostic recovery plans, and commendable performance in various cancer treatment measures.

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