Do you know this man? The chances are that if you have caught the news lately then you may have seen him! It wouldn't be quite right to say he has become an internet sensation, but his story has travelled far and wide!
This is Terry Brazier, a 70 year-old grandfather living in Hinckley, Leicestershire. Last year Terry visited Leicester Royal Infirmary expecting to be given a routine botox injection into his bladder. But as it turned out, Terry received a quite different procedure after basic identification checks were not carried out. The LRI circumcised him, resulting a year later in an award of £20,000 in compensation. You won't have to go far to find a very genial Terry talking openly and honestly about what happened to him, but as he points out there is a more disturbing side to this story. Indeed, Terry's case was one of EIGHT 'never events' reported by Leicester Hospitals in 2018.
And while it is easy to point the finger at one organisation, the fact we do know about 'never events' is that the term is very much an oxymoron. Across the NHS over the last few years we have been averaging well over 1 'never event' per day.
Of course last month saw the release of the new NHS Patient Safety Strategy and while we continue to digest this we like some of the themes, for example: more focus expertise and training for those conducting investigations, a wider range of approaches used to unpick incidents and allowing investigations teams more time to unravel why an error has occurred. To access the new strategy, visit https://improvement.nhs.uk/resources/patient-safety-strategy/
For us, the next step is to ask LRI for a copy of the root cause analysis report. Amid all the media reporting on his case and the apologies that have been given, we have yet to hear what the contributory factors were that led to this error, nor have we heard what the learning outcomes have been.
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