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Hudgell Solicitors™ | Latest News | REVEALED: The 12 NHS hospitals most regularly making ‘wholly preventable’ errors with potential to cause patients ‘serious harm or death’

REVEALED: The 12 NHS hospitals most regularly making ‘wholly preventable’ errors with potential to cause patients ‘serious harm or death’

waiting in the hospital corridor.


To the ordinary man on the street they seem completely incomprehensible – hospitals making basic, inexcusable mistakes such as operating on the wrong arm or leg – or even the wrong person – to leaving bits of surgical equipment inside patients after surgery.

It doesn’t really happen, does it?

Well, as experts in supporting thousands of victims of medical negligence in our work at Hudgell Solicitors each year, our team know the answer sadly is yes.

And despite pledges of improvement from NHS England, the number of cases are not falling.

Recently published figures showed 351 so-called ‘Never Events’ – called so because the NHS admits they should never happen – were recorded in NHS hospitals between April 1 2016 and January 31 of this year. That’s an average of more than one a day!

At Hudgell Solicitors, we were recently asked for our opinions on such errors as part of an ITV Tonight investigation into medical negligence, and the impact on victims.

We firmly believe our work plays a vital role in holding hospitals to account, highlighting their errors and providing a platform for vital lessons to be learned and improvements to be made for future patients.

We’ll continue doing part, but as you’ll see from below, many hospitals are not learning lessons quickly enough, and shockingly, a number are repeating these serious, potentially life-threatening errors.

The shocking summary of mistakes being made across NHS Hospitals

The list of ‘Never Event’ errors being made across the UK over the 10 months from April last year to the end of this January is shocking in itself. They include;

  • 143 incidents of wrong site surgery – including procedures on wrong breasts, eyes, fingers, toes, hips, ribs, elbows, legs and even the completely wrong patients
  • 89 incidents of objects being left in patients after procedures – including broken drill bits, guide wires, parts of surgical forceps, screw tabs, needles and swabs
  • 44 incidents of wrong implants – including hips, knees, lens and contraceptive implants
  • 36 incidents of medication being administered through wrong route – including oral medicine being given intravenously and mix-ups of epidural and intravenous medication

Other incidents recorded included ‘chest or neck entrapment in bedrails’ on three occasions, falls from poorly restricted windows on two occasions and scalding of a patient when soaking feet in a bowl of water.

Most regular offenders revealed in ‘NHS Improvement report

All in all it is a truly frightening NHS Improvement report, but perhaps the most frightening of all is the fact that there are many repeat offenders, and the hospitals making the most ‘wholly preventable’ mistakes – with the potential to cause serious illness or death – have been revealed to be;

  • Barts Health NHS Trust, in London – 10 Never Events

The worst offending Hospital Trust in the country with regards to Never Events. Yes, it is the biggest Trust, running five hospitals and serving 2.5m people across East London and beyond, but let’s not forget these are not events which the NHS accepts will happen every now and again – NHS England accepts they should never happen. Three times in 10 months hospitals under the Trust operated on the wrong area of a patient. Foreign objects were left in patients on four occasions, medication was administered via the wrong route twice and there was one incident of misplaced naso or gastic tubes.

  • Newcastle Upon Tyne Hospitals NHS Foundation Trust came – 7 Never Events

The second worst offender with seven incidents in the same period. The Trust runs the internationally renowned Freeman Hospital and the Royal Victoria Infirmary amongst other facilities. This Trust recorded four cases of wrong site surgery, two of retained foreign objects in patients and one of wrong route medication.

Hudgell Solicitors is currently acting on behalf of a family after a grandmother died following treatment at the Freeman Hospital in April 2015, following admissions from the Trust that her death was caused when a heart valve was mistakenly inserted upside down during an operation.

  • County Durham and Darlington NHS Foundation Trust – 7 Never Events

Seven incidents were reported by this Trust over the 10 month period, the majority (six) being surgery on the wrong site. The Trust, which runs eight hospitals and community health care services and serves around 800,000 people, was also guilty of a wrong implant/prosthesis procedure.

  • Guy’s and St Thomas’ NHS Foundation Trust – 6 Never Events

Serving two hospital sites across South East London, this Trust was guilty of making these wholly avoidable errors which can cause serious harm on six separate occasions in the 10 month period. Three cases of foreign objects being left in patients were recorded, along with two incidents of wrong site surgery and one incident of wrong route administration of medication.

  • Eight Trusts with five Never Events recorded against their names

A string of Trusts reported a total of five Never Events over the same period. They were;

  • Blackpool Teaching Hospitals NHS Foundation Trust
  • Brighton and Sussex University Hospitals NHS Trust
  • King’s College Hospital NHS Foundation Trust
  • Mid Essex Hospital Services NHS Trust
  • North Bristol NHS Trust
  • Nottingham University NHS Trust
  • Pennine Acute Hospitals NHS Trust
  • Taunton and Somerset NHS Foundation Trust

Of course, we understand that some Trusts on this list care for a significantly larger volume of patients than many others.

The NHS has also defended high numbers of Never Events by claiming it is now better at incident reporting than in previous years, leading to an increase from March 2015 onwards.

It says that, in addition, the definition of what constitutes a Never Event was amended and now requires just the ‘potential’ to cause serious harm/death to be recorded, rather than actual harm to have occurred.

However, given these incidents are ‘wholly preventable’, and by their very description should never happen, that defence has little credence.

In the cases we have handled, patients have lost lives as a result of swabs being left inside patients to hospitals failing to have appropriate bloods on standby for patients following procedures.

It is simply unacceptable and the Trusts named and shamed in this report for being the worst offenders need to address their problems quickly. If not, strong action must be taken against those responsible.

Read the full NHS Improvement report on Never Events.

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The Author

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Vince Shore

Senior Solicitor and Joint Head of Clinical Negligence

vs@hudgellsolicitors.co.uk

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