2025-113794

1. Since January 1, 2020, how many incidents have been reported to your Trust involving a wrong-site surgery? Please note that this is any incident falling under the following definition: “A medical error where a procedure is performed on the wrong patient, the wrong body part, or the wrong side of the body.” For each incident, please provide the month, year and the type of surgery involved in the procedure. In addition, please confirm the total number of cases reported between January 1, 2020, and November 7, 2025.

The Trust have had 4 incidents involving Wrong-site surgery 

·       March 2021 - wrong site colonoscopy - NOT UPHELD as a Never Event after investigation

·       October 2022 - wrong injection site / procedure - NOT UPHELD as a Never Event after investigation

·       Feb 2023 - wrong site nerve block - UPHELD as Never Event after investigation

·       Sept 2025 - wrong polyp removed - currently under investigation 

2. How many incidents fell under the definition of a serious incident, in line with the Patient Safety Incident Response Framework (or, prior to that, the Serious Incident Framework)? Please state which cases met this definition

All 4 cases at the time of reporting were felt to meet the Never Event Framework criteria and were reported national as required.  After investigation 2 were stood down as meeting the national criteria as all appropriate safety checks were completed.

3. How many incidents led to serious, moderate, or slight harm to the patient?

All 4 cases at the time of reporting were felt to meet the Never Event Framework criteria and were reported national as required.  After investigation 2 were stood down as meeting the national criteria as

all appropriate safety checks were completed.

Harm levels for the four cases:

·       Moderate

·       Moderate

·       Low/Minor

·       Moderate

4.What were the causes of wrong-site surgery incidents?

System failings identified in all four cases.  Main causes identified:

·       Unable to directly visualise area and confirm correct position of equipment, poor lighting of room,

·       Theatre booking list system not containing correct procedure on drop down list

·       Loss of situational awareness, stop before you block process not completed.

·       Currently under investigation