GREAT Western Hospitals NHS Foundation Trust has admitted another two serious surgical errors that fall into the category of an event that should never happen.

The ‘never event’ category is the most serious type of medical mistake recorded by the NHS, defined as an incident that has the potential to cause serious harm or death to a patient.

A new report from NHS England shows that in March of this year, the trust reported two such incidents – taking them now to at least four in just 12 months, equalling their worst record in recent years.

The admission comes just a month after they were forced to apologise for leaving a foreign object inside the body of a patient.

A report by the independent Care Quality Commission, published in January, warned that a lack of staff awareness showed that crucial learning opportunities were being missed after ‘never events’.

With three further such incidents in February and March, senior managers at the trust must now surely face serious questions over their failure to improve.

The latest two incidents fall into the ‘surgical’ category – one involved performing a surgical intervention on the wrong part of a patient’s body and the other saw the wrong implant or prosthesis inserted into a patient.

Only two other trusts across the country reported more than one ‘never event’ in the month of March.

NHS policy on the matter states: “Never events are wholly preventable where guidance or safety recommendations, intended to provide protective barriers, have been properly implemented.

“Occurrence of a single never event may be taken as a sign by the chief executive or relevant organisational leader that he/she must take immediate steps to ensure that patient safety systems and procedures are reviewed, ensuring that any changes required are implemented to prevent recurrence.

“Repeated never events, particularly of the same type, may demonstrate a failure of the organisation’s leadership to take patient safety seriously.”

Like other serious hospital incidents, ‘never events’ are measured over the period from April 1 to March 31 in any given year.

The two latest errors take the Trust’s total to at least four in the last reporting period compared to just two in 2014/15.

A spokesperson for the Great Western Hospitals NHS Foundation Trust said: “Of the 1.5 million patients we treat each year the vast majority have a positive experience of our services.

“We have a duty to be open and honest with our patients and on very rare occasions when errors occur we meet with the patient to apologise, explain what has happened and the action that will be taken.

"We also publish serious incidents in our public board papers.

“We were recently rated as outstanding by the Department of Health for learning from mistakes and we encourage staff to speak up so we can share learning and make improvements to the quality of care we provide.”