The NHS must learn from its mistakes

The NHS must learn from its mistakes Sharing knowledge and spreading expertise will improve patient safety

Maurice Murphy died after a nasogastric tube was passed through his nose into his lung instead of into his stomach. Murphy, the principal trumpet of the London Symphony Orchestra for 30 years, was being treated in an NHS hospital in London for a liver complaint. A junior nurse who queried whether the tube was in the right place was told by the doctor in charge: "You don't have the brain to remember that I told you to start the feed. The tube is in the right position."

Murphy, who died in 2011, was a victim of a "never event" errors so called because they should never happen. His case was recalled by Prof Sir Liam Donaldson, former chief medical officer, who told a group of NHS experts this month that never events do still happen at the rate of 300 a year in England. They include (from last year) a woman who had her fallopian tube removed instead of her appendix and 123 cases in which swabs, instruments or other items were left inside patients after surgery. Continue reading... The Guardian