STAFF shortages and low morale at the Whittington are cited in an investiga­tion report into two hospital patients who had pain-blocking treatment administered to the wrong side before surgery.

The Whittington hospital published findings about its response to the “never events” to the NHS trust’s board.

The first patient was undergoing treatment in A&E for rib fractures sustained after falling down stairs in what was described as a “life-threatening medical emergency” due to the danger of airways being blocked.

An anaesthetic of fentanyl was ordered to help with the pain but the “nerve block” was injected into the wrong side of the patient. The mix-up, which was corrected after three-and-a-half hours, meant the pain killer did not take effect.

The trust’s investiga­tion report said the wider context was an over­stretched department struggling with a rise in admissions at winter time.

It said: “There was a delay for the pain team reviewing the patient, due to capacity because of staffing levels and pressure on the service.”

It added that “theatres were busy with an emergency laparotomy and two other theatres overrunning”.

“At this time, there was a challenge to find an available operating department practitioner to assist with the procedure, due to a shortage of staff.”

The procedure is described as “complex” in the report and that managers find it “difficult to plan the skill mix on the rota to ensure the correct staff are available” for every possible scenario.

There are five consultants competent to perform this procedure at the Whittington Hospital, it said, adding: “The investigation found that there are very few anaesthetists within the trust, who have the necessary training to complete the block.”

The procedure was also carried out in a room without the necessary emergency equipment which was “not ideal, however it is a reality of the current situation with staff shortages”.

The report said that staff performing the procedure were very experienced but “under time pressures and with multiple distractions at the time of the event which does not promote a safe environment”. The trust has put a “stop before you block” checklist in response and there was a “face to face” apology.

The report looks at a second case at the Whittington, with another patient who having metal work removed from a left arm also had a nerve block installed in the wrong side.

Again the block was placed on the wrong side but suffered no long-standing harm, the report said.

The report said that there would be a review of “safe staffing levels” in the department, followed by “recruitment within the anaesthetic consultant team” and that staff would be “empowered to be able to cancel the procedure if there is not the required available team”.