Efforts to tackle so-called ‘never events’ at north Cumbria’s hospitals have seen a major culture shift, a senior consultant has said.

Tim Petheram, an orthopedic surgeon at the Cumberland Infirmary and West Cumberland Hospital, has been leading efforts to learn from past mistakes and bring in new ways of working.

The extent of problems at North Cumbria University Hospitals NHS Trust, where there were never events – wholly preventable serious incidents – between July 2015 and February 2016 have previously been revealed.

A leaked report showed they included an anaesthetic block administered to the wrong leg before surgery, a wrong eye injected, a wrong tooth extracted and a swab that was accidentally left inside a patient’s wound for six months following surgery.

The trust was also recently criticised following an inquest into two deaths, from 2012 and 2015.

Coroner David Roberts said managers were “asleep at the wheel” and failed to take vital safety steps.

Mr Petheram, who was appointed clinical lead to implement new national standards, said staff were not shying away from the problems and as a result were making great strides in addressing them.

He said the fact there had been just one never event this year showed how much attitudes had changed.

To do this they have used a National Safety Standards for Invasive Procedures (NatSSIPs) as a basis.

He said previous policies have increased the number of safety checks needed and as a result led to much more paperwork, but had not necessarily seen a drop in incidents.

“Having a piece of paper and ticking boxes doesn’t make it safe. It is about a change in culture,” he said.

“You can have reams of paperwork but then people just get sick of it.

“What makes it safe is when people really buy into it and want to be safe.”

He said NatSSIPs aim to enhance existing policies as it puts staff at the centre.

“It’s very timely and relevant,” he added.

“We are totally straight about the fact that we had a run of never events over a year ago. There was a massive problem, so this came at a good time.

“NatSSIPs is about going even further, changing how people work and how they see safety,” he explained.

Mr Petheram said culture change is not easy, so he initially delivered some presentations and group sessions to gauge reaction.

“The response was great. It generated a lot of discussion and debate.

“Not everyone agreed at first but I think people have been sold on it now. There has been a bit of an awakening.” he said.

One example is ensuring both the surgeon and anaesthetist are together when they carry out pre-surgery checks.

Mr Petheram said they looked to the airline industry, where there have been big safety improvements in recent years, for inspiration and discovered they use a lot of verbal checks from laminated cards.

“We are trying to learn from them and what has been shown to work.

“Here we are going to try something a bit new. Instead of having a big long paper form we are using a laminated card checklist.

“We do the check beforehand, then again just before surgery starts,” he explained.

“With never events, ticking boxes means nothing. They still happen.

“It’s about getting people engaged and having that proper ‘stop’ moment, where everyone in the room – or theatre – steps out of what they are doing to perform these checks together.

“It has been a real wake-up call.

“Historically the surgeon was always in charge, nobody questioned them.

“This is about empowering everyone, including lower grade staff members.

“At the end of the day every one of us could stop that never event happening.”

Asked whether older staff members were set in their ways, Mr Petheram said the key is not to introduce bureaucracy for the sake of it but actually come up with practical solutions they can see will work.

“I did worry about that, but when I did the first session people were getting really passionate,” he said.

“They have really engaged,” he added.

He said they have also had ‘human factors’ training, where teams reflect on being human and how mistakes can happen.

Mr Petheram said a recent survey showed that staff were generally positive about the new processes, though there are still ideas and concerns they can work through.

He explained that although progress has been made, this is not something they will ever stop doing.

“Nationally, never events happen everywhere. One never event in a whole year shows we have improved,” he said.

“We are not alone in having had a problem with this.

“As an organisation there has been reflection and we have set aside time for people to work on this, but it’s going to be an ongoing project.

“People have started to look at the mistakes and realise there are problems.

“I think there have been big strides in this trust to identify where our weaknesses are and look at how to improve.

“We are certainly not resting on our laurels. No one comes to work to make a mistake.”