Reference 2017-67

REF:            2017-67

Subject:        Serious Untowards Incidents




  1. The number all Serious Untoward Incidents (SUIs) reported within your NHS trust which occured during 2016 (Jan-Dec), and the details of what occured.

    Of those SUIs, how many resulted in a patient death.

    3. Of those SUIs, how many were found to be the consequence of staff fatigue or lack of sleep.



Wrong Lens implant  
Neonates – inadvertent overdose of morphine  
Wrong Site anaesthetic block  
Response to rapid deterioration  
C Diff acquisition Patient died
Missed Torsion  
Administration of Wrong Route Medication  
Wrong results reviewed leading to unnecessary surgery  
Wrong Site Aspiration  
C.Diff acquisition Patient died
Failure of equipment for lens measurement  
Medication Error – Fentanyl  
Fall – found on floor  
None of the investigations noted staff fatigue or lack of sleep as the root cause.