A hospital where six patients suffered injury as a result of dangerous errors so basic they should never happen has been threatened with prosecution by the NHS regulator.
The Care Quality Commission (CQC) has issued a formal warning to Croydon Health Services NHS Trust, which runs the Croydon University Hospital, formerly Mayday Hospital, after inspectors discovered surgical staff were failing to carry out basic safety checks.
The inspection was held in June following injuries to four patients in 18 months as a result of errors. Two undergoing cataract surgery had the wrong lens implanted, one had manipulation carried out on the wrong knee and one had a swab left inside them when they were stitched up.
Since the inspection, the CQC said, "we have been informed that two more 'never events' have occurred". The trust initially declined to provide details of the additional incidents, citing patient confidentiality, but a spokesperson later confirmed both involved swabs left inside patients.
"Never events" are incidents that should never happen because they pose a serious risk to patients and are easily avoided. Inspectors found that staff at Croydon were not using a standard surgical checklist proven to cut out such basic errors.
Croydon Health Services NHS Trust said: "We accept that 'never events' should never happen. Every patient was informed of the mistake, offered a full apology and the appropriate corrective action taken. All the patients recovered."
John Goulston, interim chief executive of the trust, said: "We are naturally very disappointed with the findings of the CQC. Within surgery we are once again confident that our surgical services are now undertaking the appropriate checklists."