AN investigation was launched after a patient had the wrong sized artificial joint replacement inserted during surgery.

The incident was highlighted in a report to the East Sussex Healthcare NHS Trust board this week.

The report said the incorrect size prosthesis was placed as part of an orthopaedic procedure.

No further details of the incident have been released by the trust.

However orthopaedic prosthetics are generally used as a replacement for joints including hips, knees and elbows.

The trust classed the incident as a “never event” and carried out a detailed scrutiny of what happened to ensure lessons could be learned from what happened.

Never events are things that happen within the NHS which are so serious they should never happen.

Each case has to be reported to NHS Improvement. The board was told four serious incidents were reported in September.

One was the never event and the other three involved a case where a patient had a fall and the other two involved the course of treatment and care for people suffering a stroke and diabetes.

Trust director of nursing Vikki Carruth said: “All serious incidents, including never events, now have executive director oversight and sign off following a robust root and course analysis of an incident.

“As part of our transparent process we will share the full report with the patient and their family on its completion and ensure any learning is embedded within the organisation.”

All four incidents are being investigated by the trust.

An external review has also been commissioned to check on the trust’s theatre services as an extra safety measure.

Never events are serious, largely preventable patient safety incidents that should not happen if existing national guidance or safety recommendations have been implemented by healthcare providers.

The national policy view is these events may highlight potential weaknesses in how an organisation manages fundamental safety processes.

They are different to other serious incidents as the overriding principle of having a list is that even one event acts as a red flag that an organisation’s systems for implementing existing safety advice or alerts might not be robust.

The NHS says the concept of the scheme is not about apportioning blame to organisations when these incidents occur but rather to learn from what happened.