‘Deficient’ processes and ‘poor’ safety culture found in trust review

A trust’s drugs control department was found to have a “significant under-appreciation of safety” and “a culture of unwillingness”, after it lost track of at least two bags of fentanyl. 

The Royal Free London Foundation Trust launched an internal incident investigation after two rejected bags of the controlled drug were reported missing from a quality control quarantine store.

Fentanyl is a strong opioid used to treat severe and/or long-term pain. But its effect is similar to heroin, it is highly addictive, and there is therefore significant illicit  use of it.

While it was not possible to ascertain if foul play contributed to the incident, the review said the incident “is most likely to represent a failure in documentation and of subsequent escalation”.

Investigators said there appeared to be a “culture of unwillingness” to train and develop staff due to the fear of losing them to other organisations. They said a “culture of fear” was inhibiting the team’s ability to “progress, innovate, and grow”.

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Source: HSJ, 24 June 2024