Probe into incidents at Blackpool Victoria Hospital

The incidents, which were reported in January, are labelled as a 'never event' but did not lead to any significant patient harm and were quickly rectified.

Never events are defined by the NHS as serious incidents that are wholly preventable.

One involved the wrong lens being implanted into a patient's eye during a cataract procedure at the Opthalmic Surgical Unit.

The other occurred on the Cardiac Intensive Care Unit and was a medication incident involving a high dose of potassium being given to a patient in error.

Members of the Blackpool Teaching Hospitals NHS Foundation Trust board of directors said they were concerned to see two never events in one month when usually there were none.

Trust chairman Pearse Butler told a meeting of the board held in public: "Never events are something we shouldn't have but in both cases the level of harm was very low."

A report to the board of directors also records a third incident involving insertion of breathing tubes in relation to an unexpected death in one of the cardiac operating theatres.

This type of incident is potentially also categorised as a never event but is currently temporarily suspended from the NHS 'never events' list.

The report says: "A third incident also reported in relation to an unexpected death in cardiac theatres (cardiothoracic), which potentially falls under the 'undetected oesophageal intubation’ category, is currently temporarily suspended from the never events list.

"All three incidents have been reported directly to NHS England and the CCGs." (clinical commissioning groups)

The meeting was also told the trust's mortality rates were now in the stastically 'normal' range for the first time, but it was a trend which needed to continue.

Medical director Dr Jim Gardner added pneumonia and respiratory disease were now the main cause of hospital deaths, with sepsis no longer the main killer thanks to measures taken to improve treatment.

Dr Gardner said: "We mustn't let the sepsis work slip but now we are focusing that energy on respiratory."