The Care Quality commission was alerted by Heart of England Foundation NHS Trust last year after a 15-year-old girl died during an operation to remove her appendix.
In a letter, the CQC urges the trust – which runs Solihull Hospital – to investigate ‘thoroughly’ and learn from serious untoward incidents (SUIs).
There were 27 such incidents between March 2007 and June 2009 including five deaths from medication errors, junior staff not raising concerns and ‘insufficient staffing levels’.
This included the death of Kings Hurst grandmother Rosemary McFarlane, 64, who was given a chemical 10 times the recommended dose, burning her lungs and killing her.
The CQC found the SUI reports did not always have clear recommendations and there needed to be a ‘clear mechanism’ to see if these had been put in place.
It notes a ‘cluster of SUIs’ within paediatrics, currently being reformed under controversial changes to maternity services at Solihull Hospital.
The letter concludes that the trust has ‘robust governance processes in place’ and a ‘clear mechanism’ to investigate and learn from incidents.
It noted the trust is working on ‘improving the culture at the trust’ to ensure incidents are reported.
It concludes: “On the basis of the information, the Commission does not have any immediate concerns relating to the safety of patients and will close this case.”
In a statement, the trust said it is reviewing medicine protocols.
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