Never Events in the Healthcare Sector

As we all know, the healthcare sector performs millions of procedures and treatments every year and the vast majority of these are successful. Occasionally, however, something goes wrong, sometimes due to the negligence of the medical professionals who are responsible for the patients’ care. While some errors can be rectified quickly and with little adverse effect on the patient, unfortunately, others can have life-changing consequences.

What is a Never Event?

A never event is a “serious patient safety incident which is entirely preventable and should not happen”. They can include surgery on the wrong body part, a foreign body being left in a patient after surgery, mismatched blood transfusions, major medication errors as well as severe pressure ulcers acquired in hospitals.

Recent examples that have happened in UK hospitals include the wrong hip replacement being put in during surgery, surgical wire being left in a patient’s arm following heart surgery, a child being given an oral drug intravenously before a kidney biopsy and the wrong fallopian tube being removed from a 27 year-old female patient, resulting in infertility.

How common are Never Events?

Between 1 April 2019 and 20 February 2020, a total of 435 never events were recorded in the NHS in England.

Why are Never Events in the news at the moment?

Last month, a hospital trust in Cornwall was warned by the care regulator to make sure surgical never events stop occurring at their sites, after a total of seven took place at its hospitals last year.

Six of the events occurred in critical care and one in the emergency department.

The Care Quality Council (CQC) said it recognised the additional pressures that staff have been under as a result of the Covid-19 pandemic but described the events that had happened at Royal Cornwall Hospitals NHS Trust as “extremely serious.”

Meanwhile, a safety watchdog has also released a national report stating that Never Events should not be defined as such if they don’t have strong enough barriers in place to stop them happening. It is recommending that seven of the 15 Never Events on the current list should be removed and no longer be described as ‘Never Events’ as the current barriers for these events do not make them ‘wholly preventable’.

The Healthcare Safety Investigation Branch (HSIB) report states that these seven types of Never Events accounted for 96% of the total number of cases recorded in 2018/19. The other eight types of event on the list happen much less often and have much stronger barriers in place, for example, restrictions to prevent falls from hospital windows and limiting access to high-strength medicines.

What recommendations does the HSIB report make?

It has made two recommendations to NHS England and NHS Improvement, suggesting firstly, that the Never Events list should be revised to remove those that do not currently have strong and systemic safety barriers in place, and secondly, that programmes of work should be developed and commissioned to find and put in place these necessary barriers.

The seven ‘never events’ recommended for removal from the list are:

• Wrong site surgery
• Retained foreign objects post-procedure
• Wrong implant/prosthesis
• Unintentional connection of a patient requiring oxygen to an air flowmeter
• Misplaced naso- or orogastric tubes
• Overdose of insulin due to abbreviations or incorrect device
• Administration of medication by wrong route

What difference will this make?

The HSIB says that changing the definition of the incidents does not diminish their importance but says that there is a discord between saying that an event should never happen and not having effective barriers in place to prevent it happening.

It argues that the events still need to be recorded and learnt from but that not having the right barriers in place and yet still defining these events in this way has an impact on the safe care of patients, affects the wellbeing of staff and reinforces the perception of a blame culture within the NHS.

Get in touch

If you think that the care that you or a loved one has received fell below the standard that you would expect, our expert team of solicitors can offer helpful, confidential advice and support. We always strive to secure the best possible compensation for victims of clinical negligence so please contact us on hello@hevans.com or call 01633 244233.