MORE than one Dorset hospital patient a month has been the victim of a ‘never event’ – a mistake so serious it should never happen – in the last year.

In the most recent incident, a person being cared for by Royal Bournemouth & Christchurch Hospital trust requiring oxygen was given the wrong type of air.

The trust is responsible for more than half of the 14 never events reported by NHS organisations in the county since the start of the 2017/18 financial year.

Never events are defined as serious incidents that are “entirely preventable” because sufficient national protections are in place and require investigation.

They can include mistakes such as surgical instruments being left inside a person following an operation and surgery being carried out on the wrong limb.

Eight of the incidents affected patients being cared for by the Royal Bournemouth & Christchurch Hospital trust with four reported by Poole Hospital and one each recorded by Dorset HealthCare and Dorset County Hospital trusts.

The figures have been published ahead of the board meeting of Dorset Clinical Commissioning Group next week.

The medical directors at Poole and Royal Bournemouth & Christchurch hospital trusts both said they encourage staff to report incidents to ensure mistakes are not repeated.

Alyson O’Donnell, medical director at the Royal Bournemouth and Christchurch Hospitals trust, said: “We take all incidents very seriously and actively encourage our staff to report them to ensure we are continually learning and improving care for our patients.

“While it is disappointing to have had a number of never events reported in the last year, the majority of these have had no or a low impact on patients.

“Extensive reviews have been undertaken to investigate each event and changes to processes have been made where necessary.

“We are proud of the open reporting culture we have here and share the incidents with our staff so they can ensure the same risks don’t exist for them.

“We have also volunteered to be part of a national review of never events and have invited a number of external individuals and organisations to review the incidents, our culture and how our services run.”

Dr Angus Wood, Poole Hospital NHS Foundation Trust medical director, said: “We care for hundreds of thousands of patients every year and we usually get it right, which is why it is so disappointing when we find we have made a mistake.

"In those circumstances, it's essential that we're open and honest about them and, importantly, use them as learning opportunities that will help us to improve our services and make them safer.

"The trust, therefore, proactively encourages all staff to be open and to report incidents, and has a 'no blame' policy so that learning can take place to prevent recurrence."

Investigation of never events is carried out by trained members of staff who produce action plans on what needs to be done to avoid mistakes being repeated.