A health watchdog carried out a snap inspection at a London hospital after a rise in the number of serious surgical safety incidents.

The Care Quality Commission visited the Royal Free Hospital on January 10 amid concerns about quality of care and an increase in ‘never events’ – “serious, largely preventable” incidents that “should not occur”.

The CQC said it was also concerned about the culture within the service.

The Royal Free London NHS Foundation Trust runs the Royal Free Hospital, Barnet Hospital and Chase Farm Hospital but only the Royal Free was inspected because five of the seven never events happened at that site.

A report published on May 19 details how inspectors found that although incidents were reported and properly investigated, front line staff did not always know about serious incidents within surgical services or could not remember lessons learned.

It said: “The service did not always manage patient safety incidents well. While staff recognised and reported incidents and near misses and managers investigated incidents, lessons learned where not always effectively shared with the wider service.”

Not all medical staff had completed training in key skills including safeguarding, and the hospital was not achieving its 90% target for mandatory training – with completion rates for most modules at 60% and 70% just 31% having completed training about exposure to radiation.

A paediatric resuscitation trolley had not been regularly checked to make sure its contents were present and up to date, and clinical risks around a shortage of ketone machines – used in treating diabetics - had not been fully recorded in the trust risk register.

And although there had been improvements, some staff reported that a few consultants still shouted and were aggressive in operating theatres. In most cases, consultants had been spoken to and made immediate apologies.

Among strengths, the CQC found that the hospital had undertaken detailed investigations into recent never events to identify causes and develop actions plans, which had been implemented.

Staff knew how to deal with sepsis, with clear protocols on recognising signs of sepsis and responding to them, but the trust had not completed an audit of sepsis compliance since 2019.

Inspectors said staffing levels were good, with a falling usage of bank and agency staff.

The report praised “effective” systems to keep patients safe, with staff reporting good access to patient information, especially if their request was urgent.

And inspectors said leaders ran services well and supported staff to develop their skills.

The Royal Free London NHS Foundation Trust received the CQC’s second-lowest 'requires improvement' rating at its last inspection in December 2019 and January 2020. Its rating is not affected by this inspection.