‘Never Events’ in the NHS

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Posted 18/02/2016 By: Amanda Cavanagh

Over the last four years, more than 1,000 NHS patients in England have suffered from medical mistakes so serious they should never have happened, according to analysis by the Press Association. 

The so-called “never events” include a case where a woman’s fallopian tubes were removed instead of her appendix and a man who had his whole testicle removed instead of a cyst. There were other noted “never events” such as wrong legs, eyes or knees being operated on and hundreds of cases of foreign objects, such as scalpels, being left inside patients’ bodies after operations. Patients have been given the wrong blood type during transfusions or wrong drugs or doses of drugs.

The “never events” totalled 1,188 from April 2012 to December 2015. NHS England insisted “never events” were rare – affecting one in every 20,000 procedures – and that the majority of the 4.6 million hospital operations each year were safe.

NHS England has insisted that such events are rare, but Katherine Murphy, chief executive of the Patients Association said: “It is a disgrace that such supposed ‘never’ incidents are still so prevalent. How are such basic, avoidable mistakes still happening? There is clearly a lack of learning in the NHS. It is especially unforgivable to operate on the wrong organ, and many such mistakes can never be rectified.”

The Press Association analysis also found that patients’ lives were put in danger when feeding tubes were put into their lungs instead of their stomachs.

A spokeswoman said: “One never event is too many and we mustn’t underestimate the effect on the patients concerned. To better understand the reasons why, in 2013 we commissioned a taskforce to investigate, leading to a new set of national standards being published last year specifically to support doctors, nurses and hospitals to prevent these mistakes. Any organisation that reports a serious incident is also expected to conduct its own investigation so it can learn and take action to prevent similar incidents from being repeated.”

Amanda Cavanagh, a member of the clinical negligence team at Ashtons Legal, comments: “It surprises me that yet again money (which the NHS can ill afford), has been thrown at an issue which required a committee to investigate and a new set of standards to be published, to sort out something which to the lay person seems pretty basic. Precise, legible and complete record keeping along with reference to these records before, after and during surgery, would solve the majority of these never events”.


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