Three ‘never events’ reported at health board during February

Details of three new ‘never events’ reported last month have emerged as the Betsi Cadwaladr health board gave a performance update.

A ‘never event’ is a “serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented”. There were 37 never events at hospitals in Wales between April 2021 and March 2022 – 12 in Betsi Cadwaladr health board, 10 in Aneurin Bevan health board.

The details from the agenda bundle for a health board meeting says the following on the three new never events that were reported in February 2024:

• Wrong Site Surgery: Patient undergoing amputation of 2nd and 3rd toes had an
  incision into the 4th toe instead of the 3rd, however stopped and proceeded to
  amputate the correct toe.
• Wrong Procedure: Patient had mirena coil inserted after category 2 caesarean
  section which had been planned for a different patient. The list order was changed
  due to the increase in category for this patient.
• Wrong Route (Medication): Patient was unable to swallow oral medication,
  medication was crushed and mixed with water in a syringe and inadvertently given
  IV.

The performance report also gives a snapshot of the wider health board, noting, “Of the measures from the NHS Wales Performance Framework included in the report, 18 are on target, 32 are off target and six are a cumulative basis.”

Wait times in Urgent & Emergency Care are detailed, “After remaining consistent around the 69% mark in quarter 3 of 2023-24, quarter 4 has seen a consistent decline to 65.4% in performance in the percentage of patients experiencing waits over 4 hours in our Emergency Departments. Patients experiencing waits of over 12 hours remains over the 3,000 mark and remains an area of escalation within the service.

“The number of ambulance handover delays of an hour or more continues to be of concern, currently reported at 2,322 and the number of patients delayed over 4 hours in an ambulance remains static at just over 890 (although still 200 fewer than seen a year ago).

“Delayed pathways of care remains a key concern for the Health Board as the number is increasing with over 362 patients experiencing delays in their pathway and no significant change seen since April 2023.”

The ‘many challenges’ referenced can be seen in specific wait time data, with it revealed that despite numbers falling over the previous six months the number of patients waiting
over 8 weeks for a diagnostic test has been increasing for the last two months and is at 6,836.

The number of patients experiencing waits over 14 weeks for therapy interventions “continues to increase” with 4,265 patients waiting in February, double the 2,102 reported in June 2023.

The number of patients waiting over 52 weeks for a new outpatient appointment has “continued to rise” through the fiscal year and is now at 14,929 compared to 12,000 in April 2023.

Context to that figure is given with “continuous reductions in the number of patients waiting” over 208 weeks – down to 244, 156 weeks – down to 1,436 from 3,359 in April 2023 (63% reduction), 104 weeks – down to 7,970 from approx. 9,500 in April 2023.

However the report states, “The number of patients experiencing a delay of over 100% of their waiting time for a follow up outpatient appointment has decreased to 87,859 compared to the 91,334 previously reported.”

On HR, it adds, “Turnover rates of nursing and midwifery staff remains consistent at 1.6% since December 2023. Sickness absence has increased at 6.4% (compared to 6.2% reported previously)
with stress and other mental health issues continuing to be the main reason for sickness absence. The percentage rate of agency spend as a proportion of the total pay bill continues to fall”

Elsewhere there is reference to physiotherapy waits, due to “…high number of vacancies, accommodation capacity in Central and East, cessation of locum support, increase in inpatient demand and urgent referral demand.”

The performance section concludes, “The Health Board continues to face challenge in attainment of the performance targeted within the national and local plans. However, it is of note that in a number of areas performance continues to improve (based on historic delivery and in year comparison). “