A SERIES of concerns have been raised about the care provided at the University Hospitals Dorset Trust, including seven occasions of staff failings which led to a delay in cancer treatment.

UHD was inspected by the Care Quality Commission shortly after the merger between the Royal Bournemouth and Christchurch Hospital and Poole Hospital trusts.

The concerns related to high number of never events reported in the period from March 2020 to January 2021. Never events are serious, largely preventable, patient safety incidents that should not happen.

Other concerns related to an incident of a breach of information governance; a small number of patients being referred to the trust whose treatment had either not been carried out, or not followed-up on in a timely way; and an incident which gave rise to concerns around employment of temporary staff.

The CQC report said: “In relation to our concerns around never events, the trust had governance processes which reviewed these events at sub-committee level both individually and collectively.

“Each had been investigated and action plans approved to look at how to prevent these occurring in future.

“The investigations were brought to the trust’s care group governance meetings and then reported to the quality governance group.

“This committee produced a quality report to the board each month. However, the board papers did not demonstrate recognition of the rise in these events to become a statistical outlier over the 11-month period where 13 events took place.

“In relation to our concern about patients being delayed in cancer treatment or the pathway not completed in error, the procedures for managing patients with unexpected diagnosis of cancer were not always being correctly followed.

“The governance system did not have sufficient assurance to recognise these breaks occurring in a patient treatment pathway, or delays through failings in paperwork.

“Following our inspection, the trust investigated the incidents we raised, which considered eight specific events, and was able to report that all but one showed some failure by staff to follow process as a contributory factor.”

Catherine Campbell, CQC’s head of hospital inspection for the south west, said: “During the inspection, we found leaders had the skills and abilities to run the service.

“However, governance systems were not always effective in determining patients’ pathways of care and treatment.

“In a small number of cases of patients being treated for cancer at Poole Hospital, the system used did not prevent treatments from being missed, delayed or terminated in error.

“We recognise the trust had taken steps to address these gaps, but until the system is tested and these fully investigated, the risk to patient care and treatment still remains.

“Inspectors have made clear to the trust where action is needed, and we continue to monitor their progress to ensure improvements are made and thoroughly embedded.”

Dr Alyson O’Donnell, chief medical officer of UHD, said: “We’re grateful to the CQC for their report, which identifies a strong leadership and safety culture, and a desire from all staff to learn and improve at UHD.

“It also highlights areas where we can do better, and we will continue our focus on all of the areas the report addresses and where improvements are needed, including developing and embedding further robust governance and oversight structures.

“Whilst this inspection was conducted just a few months after the merger between Poole and the Royal Bournemouth and Christchurch hospitals trusts, and at a time when the hospitals, the NHS and the world’s health communities were responding to the Covid-19 pandemic, the report also found notable positives around how the hospitals are run and managed, and acknowledges a range of safety improvements have already been completed or are underway.”