Public Board papers 31.03.22

1. Safe

1.2 - Serious Incidents and Never Events

Never Events – are defined are serious incidents that are wholly preventable The last Never Event occurred in January 2020 which was the only incident in the last 5 years.

Serious incidents There was 1 serious incident declared in February; W67258 2022/1642 potential missed opportunity to identify and treat a deep vein thrombosis 2 serious incidents were stepped down following serious incident panels; W65286 – unable to conclude in absence of a post mortem if event attributable to the stent or recurrence of disease W65260 - rare recognised consented but unintended complication, earlier admission would not have prevented the outcome

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