The Healthcare Safety Investigation Branch (HSIB) has today published its first investigation report relating to a surgical never event.  

The patient is a 63-year-old man who underwent hip replacement surgery. During this surgery, incompatible components were used. The error was identified when data from the procedure was recorded in the National Joint Registry.  

HSIB's investigation centred on how the error occurred and what recommendations could be made to reduce the risk of a similar event happening again. The investigation team observed similar surgical procedures in England and in Denmark as part of the investigation process.  

HSIB's Chief Investigator, Keith Conradi said

'This first report is the culmination of many months of rigorous and independent investigation, working closely with those involved in the incident, as well as relevant organisations and subject matter experts.'

See full statement here 

The patient, Mr Hampton, gave his view on the investigation and his experience at the Trust 

'I think it’s a good idea because a national investigation can make all hospitals better; they are good already but this could make them even better. As long as mistakes can be learnt from that’s what you want and so I think it’s brilliant there’s been a national investigation.'

'I think the staff at the hospital are brilliant – from the surgeon to the people who cook the food. Everybody was fantastic to me. I don’t want any staff to get into trouble over a mistake, we all make mistakes.'