The NHS defines a “Never Event” as a serious incident that is wholly preventable and has the potential to cause serious patient harm or death. Although, serious harm or death does not need to have actually occurred.
Between April 2021 and March 2022, NHS Trusts in England recorded over 400 “Never Events”. This included medical equipment – drill bits and wire cutters – being left inside patients by mistake. This totals almost 8 incidents across the country each week and represents a 14% increase from the previous year.
The recently published data revealed:
- 98 cases of a foreign object being left inside the patient, including 32 vaginal swabs and 21 surgical swabs.
- One patient had a part of a scalpel blade left within their body, while another was found to have a bolt from surgical forceps.
- 171 incidents where surgery was performed at the wrong site.
- 1 woman had her ovaries removed by mistake.
- 12 incidents where the wrong hip implant was performed.
- 11 cases where the wrong knee implant was performed.
- 13 incidents where the patient was incorrectly connected to air instead of oxygen.
- 7 cases of the wrong blood type being transfused.
- 1 incident where a patient underwent breast surgery without consent.
- 6 patients experienced treatment to the wrong eye.
- 11 cases where patients received an overdose of insulin.
A further 29 cases were reported as “Serious Incidents” but did not strictly fit the definition of a “Never Event”.
It must be noted that whilst Never Events have increased in the past year they still represent only a small fraction of the overall number of procedures that are successfully performed.
A Never Event should not happen if the healthcare providers have followed existing national guidance and safety recommendations, which include:
- Explaining the procedure and obtaining informed consent
- Marking the correct body part before surgery
- Accounting for all surgical implements and equipment
- Checking medical history for blood type and medication allergies
When we discover that a Never Event has occurred it is often from a compounding of several smaller mistakes but nearly always a result of human error from the pressures of work.
It is important that procedures carried out by the NHS are performed safely and correctly to ensure that patients feel a level of trust with their clinicians. The NHS reports Never Event data each month as it is recognised as an important part of the evaluation process to help to prevent such mistakes being repeated. They also have a duty of candour to report any mistakes, including never events, to the effected patient.
A Never Event is considered to be largely indefensible and it may therefore give you strong grounds to bring a medical negligence claim if you have been injured or left in a worse condition as a result.
If you have been affected by a “Never Event”, please get in touch with one of our medical negligence specialists, who will be able to discuss how we can help you.
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