NHS England Find 148 ‘Never Events’ At Hospitals Over A Six Month Period

13 December 2013

NHS England Find 148 ‘Never Events’ At Hospitals Over A Six Month Period

Figures released by NHS England have shown that almost 150 ‘Never Events’ occurred from April to September 2013 across a number of hospitals.

The term refers to incidents within a hospital that should ‘never happen’ due to their seriousness and include examples such as wrong site surgery and the retention of foreign instruments within a patient’s body after surgery. There were found to be 148 such events in the six month period looked at across various hospitals, including events such as the wrong patient receiving heart surgery, patients given overdoses and one woman who was awaiting appendix surgery, and had her fallopian tube removed instead.

There were 69 cases where foreign objects were left inside patients, including 11 cases of surgical swabs, one patient who had wires left inside and another patient who was left with a needle in their body as well as three cases where specimen retrieval bags were left inside and in one particular case where a drill guide block was left inside the patient's body.

Dr Mike Durkin, national director of patient safety at NHS England, said: 'Awareness in the NHS of these issues has never been greater and the quality of our surgical procedures has never been better. It follows that the risk of these things happening has never been smaller.

'Every single never event puts patients at risk of harm which is avoidable. People who suffer severe harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS.

'But is time for some real openness and honesty. There are risks involved with all types of healthcare.

'And one of those risks - with the best will in the world and the best doctors, nurses and other healthcare professionals in the world - is that things can go wrong and mistakes can be made. This has always been the case, and it is true everywhere in the world.'

Some of the other ‘Never Events’ highlighted by NHS England included instances where:

-37 patients had the wrong part of their body operated on or treated, including four operations on the wrong tooth, an operation on the wrong toe, a patient who had an injection in the wrong eye and one case where a woman had the wrong fallopian tube removed during an ectopic pregnancy, placing great risk towards future fertility.

-The wrong patient undergoing a heart procedure, and a wrong patient given a colonoscopy to check their bowel.

-The death of two patients, the first as a result of failure to monitor their oxygen levels, with the second patient being a woman who died from heavy bleeding following a planned Caesarean section.

Some of the hospitals highlighted as having experienced the higher number of ‘Never Events’ included:

Gloucestershire Hospitals NHS Foundation Trust

Leeds Teaching Hospitals NHS Trust

Norfolk & Norwich University Hospitals NHS Foundation Trust

Sheffield Teaching Hospitals NHS Foundation Trust

South Tees Hospitals NHS Foundation Trust

The Royal Wolverhampton NHS Trust

University Hospitals of Morecambe Bay NHS Foundation Trust

West Middlesex University NHS Trust

and Newcastle Upon Tyne Hospitals NHS Foundation Trust having the most number of ‘Never Events’.

Professor Norman Williams, president of the Royal College of Surgeons suggested the publication was welcome and its findings were intolerable. He said: 'Never events are incidents that are completely unacceptable. However rare these cases are, never should mean never, and avoiding such errors should be the priority of every surgeon.'

If you feel you have experienced such a 'Never Event' whilst at hospital, we have a number of specialists in this area who can provide advice and support to you so you know your patient rights.

If you have experienced any form of medical mistreatment at any NHS trusts, hospitals or want to better understand exactly what your patient rights are, we are pleased to offer advice and support to you. Our specialists have wide experience of providing advice and support across a number of areas relating to potential medical mistreatment, such as misdiagnosis and delay and surgery errors, for example.