Patient sent home from hospital with cannula left in
Patients will be monitored more closely at two hospitals after a person was discharged with a cannula still in.
The family of the patient complained over the blunder at Sandwell Hospital in December.
Toby Lewis, boss of the Sandwell and West Birmingham NHS Trust which runs the hospital, called the failure "disappointing", particularly as doctors had been told to be aware of retained cannulas following a similar issue three years ago.
Mr Lewis has ordered every discharge to be monitored "until we are confident that this was solely an isolated mistake".
The mistake was flagged up in a new report to the trust board, in which the chief executive said the family of the unidentified patient has "raised real questions about our care and our response".
A retained cannula is classed as a never event, meaning it shouldn't happen under any circumstances.
A cannula is a tube that can be inserted into the body to give or take fluids or for gathering samples.
Chief executive Mr Lewis said in his report: "It would not be appropriate to discuss individual complaints and concerns in this report.
"However, I want to acknowledge our evident failure in respect of an unremoved cannula in a patient, whose family have raised real questions about our care and our response.
"This is even more disappointing given that three years ago we put in place specific discharge checklist additional arrangements on this matter arising from a prior complaint.
"Alongside the February audit data we are collating on our never event changes I have therefore asked us to collect positive assurance data on every discharge from our care until we are confident that this was solely an isolated mistake.
"The Never Event list is important, but where we find serious acts and omissions locally, we must regard those with equal seriousness."
Chief Nurse Paula Gardner said: “We are sorry for the circumstances that led to one of our patients incorrectly being discharged from Sandwell Hospital with a cannula in situ last December. We are disappointed that our specific discharge checklist was not followed in this instance and are now collecting data to be assured this was an isolated mistake.”
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