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June 22nd 2021

Medical Negligence

NHS records 2,272 Never Events in five years – but what are they?

Hayley Collinson

Hayley Collinson

Associate, Clinical Negligence

NHS records 2,272 Never Events in five years – but what are they?

At Hudgell Solicitors we are experts at dealing with cases of medical negligence around errors which are ‘wholly avoidable’ if the proper checks and procedures are followed – such incidents are classed as ‘Never Events’ by NHS England.

At Hudgell Solicitors we are experts at dealing with cases of medical negligence around errors which are ‘wholly avoidable’ if the proper checks and procedures are followed – such incidents are classed as ‘Never Events’ by NHS England.

They are occurrences that require a serious incident investigation, and NHS England produces monthly and annual reports on the number of Never Events that occur.

NHS England states: “The NHS in England is one of the only healthcare systems in the world that is this open and transparent about patient safety incident reporting, particularly around Never Events. We are clear that we need to openly tackle these issues, not ignore them.”

What are the 15 categories of errors classed as a Never Event?

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.

Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened for that incident to be categorised as a Never Event.

Never Events may occur in a variety of situations. As part of its reporting, there are 15 types of Never Events which were defined by the NHS in an updated list in February 2018. These are:

  1. Wrong site surgery
  2. Incorrect implant/prosthesis
  3. Retained foreign object post procedure
  4. Mis-selection of a strong potassium solution
  5. Administration of medication by the wrong route
  6. Overdose of insulin due to abbreviations or incorrect device
  7. Overdose of methotrexate for non-cancer treatment
  8. Mis-selection of high strength midazolam during conscious sedation
  9. Failure to install functional collapsible shower or curtain rails
  10. Falls from poorly restricted windows
  11. Chest or neck entrapment in bed rails
  12. Transfusion or transplantation of ABO-incompatible blood components or organs
  13. Misplaced naso- or oro-gastric tubes and feed administered
  14. Scalding of patients
  15. Unintentional connection of a patient requiring oxygen to an air flowmeter

How many Never Events happen a year?

In the five years between April 1, 2016 and March 31, 2021, there were 2,272 Never Events recorded by NHS England that fall under one of those 15 categories.

Between April 2020 and March 2021, 364 Never Events occurred, with the majority of these being wrong site surgery (142) and retained foreign object post procedure (80).

There were also 30 errors of incorrect implant or prosthesis, while the report also included incidents such as eight times the wrong blood was transfused and one occasion when a patient became trapped between their mattress and bedrail.

The 364 Never Events was a fall of 108 on the previous year, although a reduction in the number of medical procedures carried out during the Covid-19 pandemic lockdowns may explain this decline.

Number of Never Events

Due to the Never Events list changing in February 2018, which included changes to some of the definitions and the addition of new types, reports covering periods since then “are not comparable with earlier reports”, according to the NHS.

When did Never Events lead to a claim for compensation?

On the back of figures showing Never Events had reached a four-year high, the problem of errors in the NHS was highlighted in a documentary aired on ITV in March 2017 called ‘NHS: Medical Blunders Revealed – Tonight’.

The broadcast told the stories of three victims of serious medical errors, including one case in which Hudgell Solicitors represented the family of a man who’d had a surgical swab left in him for 13 years after surgery.

Luton and Dunstable Hospital left a swab in patient Frank Hibbard’s pelvis while removing his prostate. When he died of cancer 13 years later, a coroner said the swab had contributed to his death, as a mass the size of a large grapefruit was found to have grown around the calcified swab when his health deteriorated.

Other times Hudgell Solicitors helped clients gain compensation after a Never Event included:

  • A surgeon with over 30 years’ experience operated on the wrong part of a 61-year-old man’s arm – confessing to his mistake soon after the nerve decompression surgery had ended. Read the full story here >> 
  • An epileptic patient, 50, was hospitalised for 11 days after being given antibiotics he was allergic to. Read the full story here >>
  • A first-time mum, 27, was left in agonising pain following the birth of her son after ‘packing’ used to stem bleeding after the birth had been accidentally left inside her for five months. Read the full story here >>
  • A woman was left with a ‘large open hole’ in her eye and unable to bear sunlight after laser surgery was mistakenly carried out too low. Read the full story here >> 

What is the NHS doing to learn from Never Events?

The NHS says that “the overriding principle” of having the Never Events list is that even a single error acts as a “red flag that an organisation’s systems for implementing existing safety advice/alerts may not be robust”.

In January 2018, it published a revised Never Events policy and framework in which it stressed that it “is not about apportioning blame when these incidents occur, but rather to learn from what happened”.

For this reason, the revised framework removed the option for commissioners to impose financial sanctions when Never Events were reported, which it said “reinforced the perception of a blame culture”.

The framework stated: “Our removal of financial sanctions should not be interpreted as a weakening of efforts to prevent Never Events. It is about emphasising the importance of learning from their occurrence, not blaming.

“Learning from what goes wrong in healthcare is crucial to preventing future harm, but it requires a culture of openness and honesty to ensure staff, patients, families and carers feel supported to speak up in a constructive way.

“The revised Never Events policy and framework are designed to support the NHS to do that, and are part of continuing efforts to build a learning culture and maximise opportunities to keep our patients safe.”

Its commitment to lifelong learning means that when a Never Event occurs, regardless of the outcome, the problems in care are identified and analysed through a full investigation, such as a root cause analysis (RCA), to understand how and why they occurred and so that “effective and targeted actions can be taken to prevent recurrence”.

The framework concludes that “…a patient safety incident cannot simply be linked to the actions of the individual healthcare staff involved. All incidents are also linked to the system in which the individuals were working. Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring”.

What should you do if you think you have a Never Event claim?

If you or a loved one has has fallen victim to a Never Event and suffered as a result, you may be entitled to pursue a clinical negligence claim for compensation.

We at Hudgell Solicitors have dealt with a variety of claims of this nature and our team of experts are on hand to advise you every step of the way to find out if you have a claim to make.

At Hudgell Solicitors, we are committed to ‘Righting Wrongs’ and the majority of cases we handle are funded by no win no fee agreements.

Get in touch today for free, no obligation advice on your case.

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