MEDICAL errors that are so serious they should never happen are classed as ‘never events’ – but a report shows Swindon’s Great Western Hospital has now experienced three such events in twelve months.

The sort of errors that come under the title include operating on the wrong person, amputating the wrong leg or even leaving bits of surgical kit inside a patient.

They are defined by the NHS as mistakes that have the potential to cause serious patient harm or death, although no harm or lasting impact has to be caused for such a mistake to be classed as a never event.

A new report released by the hospital has shown that in February, a foreign object was left inside a patient following surgery.

And in August last year an unscheduled endoscopy procedure was carried out on the wrong patient.

In the third 'never event' in March 2015, surgical sponge used to pack the throat of a patient having his teeth removed was left in place – the patient had to be re-anaesthetised to remove it.

Although GWH has not released many details of the most recent incident, a report from the Wiltshire Clinical Commissioning Group revealed that the object was a piece of surgical gauze which had come apart during the procedure.

A subsequent investigation found that the particular type of gauze being used was liable to rip and separate easily in saline and other solutions, the remaining stock was quarantined and a national alert was raised.

While that incident was put down to an equipment failure, the never event in August last year was recorded as human error.

A report by the Care Quality Commission published in January also noted that when asked, staff in other areas of the hospital were not aware that the incident had even happened – an indication that crucial learning opportunities were being missed.

The medic responsible is still working at GWH.

Never events, like other serious hospital incidents, are measured over the period from April 1 to March 31 in any given year.

GWH recorded 2 such incidents within the last reporting period, the same as the previous year.

Both years show some improvement on the figures from April 2013 to March 2014 during which time foreign objects were left in patients 4 times during a single year.

A spokesman for Great Western Hospitals NHS Foundation Trust said: “This incident, which occurred last August, refers to a test given in error which was described as causing low harm to the patient.

“We have apologised to the patient and their family and have explained what happened.

“Changes have now been made to strengthen the consent process.

“We have a strong reputation for being open and honest, and were recently rated as outstanding by the Department of Health for learning from mistakes.

“This is because we know that openly recognising mistakes leads to improved patient safety and we encourage staff to speak up so we can learn and make improvements.”