Patient Safety & Never Events In Clinical Practice

The BBC reported in the last week that Shrewsbury and Telford Hospital NHS Trust had launched an investigation after the wrong tissue was removed during a surgical procedure at one of its hospitals in July of this year.

The patient had two lesions, but the wrong one was removed in the first operation.

This was classed as a surgical “Never Event” and was reported to the board of the Trust for a full investigation.

But what exactly does a Never Event mean in clinical practice?

What is a Never Event?

Never Event is the term given to serious, preventable, safety incidents within clinical practice that should not occur if the available preventative measures are implemented.

The NHS defines a Never Event as:

In the simplest terms, these events occur because the correct and available preventative measures were not in place. They are a serious threat to patient safety and have the potential to cause significant harm, or even death.

When a Never Event occurs in a healthcare setting such as a hospital, this must be reported and there are regulatory consequences, and the Care Quality Commission, who are the independent regulator for health and social care in England, becomes involved.

Never Events could highlight potential weaknesses in how a healthcare provider manages fundamental safety processes, and it is clearly vital that lessons are learned from any such event as a matter of priority and to offer protection from future issues.

Examples of Never Events

The list of incidents which would be classed as a Never Event includes:

The Never Events framework and policy

The Never Events policy and framework were developed to support the NHS to learn from such events in an attempt to prevent future harm. It is considered to be part of continuing efforts to build a learning culture and maximise opportunities to keep patients safe.

The policy and framework set out that the Chief Executive, all board members, other relevant organisation leaders, and all relevant teams within the clinical setting in question should know about any Never Event occurring in their organisation.

A Never Event requires full investigation, which includes the need to fully and meaningfully engage patients, families, and carers at the beginning and throughout any investigation.

The organisation’s leaders are then responsible for ensuring that any occurrence of a Never Event is analysed in full to understand how and why it occurred. They must then ensure that actions that measurably reduce the risk of recurrence are taken.

How often do Never Events happen?

NHS England regularly publishes data relating to Never Events in the NHS across the country.

Data for the last few years reveals:

You can read the Never Event data in full here.

Which Trusts had Never Events?

The Ten NHS Trusts with the most recorded Never Events in 2022/23 are as follows:

2023 Never Events data

Looking at this year in more detail, NHS England’s provisional data for 1 April to 31 August 2023 shows that:

Medical negligence claims for Never Events

Never Events are clearly a significant breach of patient safety. These events are serious and can lead to devastating injury to a patient, or even death.

The most concerning aspect of Never Events is that, with the correct measures in place, these events should not happen.

The healthcare provider involved should report the incident and a full investigation should take place. However, you may wish to consider taking the matter further.

If you or a loved one have suffered following a Never Event, you could very well be entitled to claim compensation for your injuries through a clinical negligence claim.

It is important to seek the advice of specialist solicitors if you think you may have suffered injury as the result of a Never Event. Here at Nelsons, we have assisted many clients who have experienced the impact of a Never Event.