Call for “deep dive” into serious incidents at NHS trust hospitals in Basildon, Southend and Chelmsford

An Essex hospital trust clocked up 85 serious incidents on its wards in three months including a blood clot removal procedure on the wrong leg, it has emerged.

Latest figures for the Mid and South Essex Clinical Commissioning Group joint board show there were five incidents involving the “wrong surgical site”.

This included an angiogram and thrombectomy on the wrong leg between November and January at Southend, Basildon and Broomfield hospitals.

Speaking at the latest board meeting last month, Stephen Mayo, interim director of nursing for patient experience at Thurrock CCG, called for a “deep dive” into what caused the incidents.

He said: “There were 85 serious incidents across the acute during this period and one never event which related to an angiogram commenced on an incorrect leg.

“This brings the total of never events during this time period to five. Four of them are related to wrong site surgery and one to a medication incident within maternity.

“We have requested that there is a deep dive regarding these never events and reporting to our system quality group. They need to take as part of that reporting process the impact on patients and staff within their investigation and going forward.”

Other surgery carried out on the wrong site includes two ophthalmology cases and one in orthopaedics. An insulin overdose was also administered at a maternity unit.

Serious incidents recorded included an alleged abuse of a patient at Southend, pressure sores at Basildon Hospital and trips and falls and delayed diagnoses at all three hospitals.

During November, December 2021, and January 2022, 69 cases were closed or de-escalated across Mid and South Essex. This left a balance of 217 open serious incidents across the organisations with 172 of these within acute commissioning.

There remains a total of 36 active 2020/21 cases and there are currently 76 “stop the clocks” – any cases that now become overdue will be marked as stop the clock due to the COVID pandemic rather than breaching.

A further three cases have been given an extension.

The Royal College of Surgeons review of Urology Specialist Services took place in November 2020. The report was received by the hospitals in February 2021 and set out four urgent recommendations and six additional recommendations aimed at supporting improvement.


Christine Sexton

Local Democracy Reporter