What are never events?
NHS England define never events as:
“…serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.”
Each year a report is published by NHS England detailing the type and number of never events reported by each trust.
Never event statistics for 2021/22
407 never events were reported to have occurred between 1 April 2021 and 31 March 2022. This is an increase from the 2020/2021 period in which 364 never events were reported.
Reported events this year included:
- 171 incidents of wrong-site surgery.
- 98 incidents of a foreign object being left inside a patient after the procedure. This included three incidents of part of a drill bit, 32 vaginal swabs, 21 surgical swabs, and numerous other objects, including part of a pair of wire cutters and a scalpel blade.
- 21 incidents of surgical swabs being left in patients.
- 12 incidents of the wrong hip implant and 11 cases of the wrong knee implant being used.
- 11 incidents of insulin overdoses being administered.
- Seven incidents of the wrong blood being transfused.
Manchester University NHS Foundation Trust reported 11 never events, the highest across the country.
University Hospitals of Leicester NHS Trust, Nottingham University Hospitals NHS Trust, Sandwell, and West Birmingham University Hospitals NHS Trust all reported 10 never events.
An NHS spokesperson said:
“While these events are extremely rare, and NHS staff are working hard to provide safe care to patients, it is important that events are reported and learned from so that they can be prevented in the future.”
In 2018 the never events policy and framework were revised. This removed the option for commissioners to impose financial sanctions when never events were reported which it said, “reinforced the perception of a blame culture”.
Comment
By their very definition, never events are entirely preventable.
This, therefore, raises questions and concerns over how 407 people came to suffer avoidable harm in the last year.
Whilst each incident is identified and analysed through a full investigation, the outcome of which implements new measures to prevent a recurrence, the statistics tell us that similar events continue to reoccur.
How can we help?
Georgina Sheppard is a Paralegal in our expert Medical Negligence team, which is ranked in tier one by the independently researched publication, The Legal 500.
If you believe you might be a victim of a never event or any other medical error, please do not hesitate to contact Georgina or another member of the team in Derby, Leicester, or Nottingham on 0800 024 1976 or via our online enquiry form.
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