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Royal Cornwall Hospital Requires improvement

All reports

Inspection report

Date of Inspection: 25 January and 25 May 2011
Date of Publication: 29 June 2011
Inspection Report published 29 June 2011 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Meeting this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

Our judgement

Patients are at an increased risk because important safety check-lists are not consistently being completed or used effectively in the operating theatres at the Royal Cornwall Hospital.

Patients are at an increased risk as the consent forms, typed theatre lists and information on the white boards in the operating theatre do not always say the same thing,

User experience

During our site visit we saw numerous examples where surgical safety checks were not being carried out in a satisfactory or consistent way within operating theatres at the hospital. This is despite five ‘Never Events’ occurring in the operating theatre departments since 2009, (the most recent being in April 2011), subsequent internal investigations by the hospital and actions plans developed as a result of these. ‘Never Events’ are serious, largely preventable, safety incidents that should not happen if the available preventative measures have been put into place.

Royal Cornwall Hospital sometimes use an adapted version of the World Health Organisation (WHO) surgical safety checklist recommended by the National Patient Safety Agency (NPSA). The surgical safety checklist consists of safety checks done at various stages of the person’s journey through the operating theatre. The WHO state that these checks should be clear, formal and read out loud.

Staff told us they thought they were very good at performing surgical safety checks but said it did depend on which staff were on duty as to how well the checks were done.

Our observations found that staff are not following the WHO guidelines and do not always refer to the hospitals adapted checklist. As a result they do not complete all core checks which meant there was an increased risk to some patients because important checks are not completed at an appropriate time or not communicated to all team members.

Staff told us that there is a ‘Department meeting’ each morning where the theatre list is discussed with complications and important information discussed. Staff told us that Surgeons and Anaesthetists are not always included in this meeting.

A detailed ‘sign in’ check should be performed before the anaesthetic is given to the patient. We saw an example where airway, estimated blood loss and equipment checks were not performed. The remaining checks were also not clearly communicated.

Just before the operation commences a ‘time out’ check is conducted where staff make sure the next stage of the checklist is complete. During our observations time out checks were not clear and in one case chaotic with a quiet time not being adhered to. This meant that important information was missed or needed to be repeated.

During the eight ‘time out’ checks we saw none were clear or formally done. Four checks did not introduce the staff present in theatre and three did not discuss antibiotic therapies. Two checks did not discuss prevention measures for pressure sores. One of these was on an elderly person where no padding or hip protection was used under a hip despite the person being at very high risk of developing pressure sores. In the same case specific pressure relieving equipment was not used on other parts of the body. Incontinence pads were used for padding, which may crease and further the risk of pressure sores developing. Theatre staff also identified that the person had an artificial hip in place which they had not been informed about and were also delayed starting because they had not been informed that ward staff had not performed all pre operative checks, meaning operating staff had to get further equipment. This meant the person was waiting for an extra five minutes with specialist anaesthetic in process, which could have worn off needing further anaesthetic.

During another time out check the surgeon was ‘scrubbing up’ (washing his hands and putting on sterile gown and gloves) so missed the majority of the surgical safety check. Possible critical events or risks were not discussed and the name of the procedure was not announced to the theatre team as expected according to the WHO checklist and hospital checklist. The consent form for this patient varied very slightly to the procedure on the board. This lack of clarity could lead to errors being made. This operation was being carried out by a registrar grade surgeon. The assistant was also acting as a scrub nurse. We were t

Other evidence

Unspecified