Why are Never Events always happening?

The thought of such an event is unthinkable. So why are these medical blunders becoming an everyday occurrence within the NHS?

Data released by the NHS earlier this year states that 384 never events occurred between April 2022 and March 2023, with as many as 43 a month. Figures from the same period of the previous year show that cases are on the up. Since 2015, there have been between 400-500 recorded Never Events every year.

It is important to point out that Never Events are rare and extreme. Most clinicians work hard to ensure procedures are successful without issue.

But we are all well aware of the current pressures crippling the NHS. Could the occurrence of Never Events be exacerbated if overworked or undertrained staff are performing treatment within unreasonable time constraints? As clinical negligence specialists, we know that if the healthcare system is overstretched, there is an increased risk that mistakes will happen.

What are Never Events?

Never events are unforgivable lapses in patient care. They are serious incidents that are wholly preventable and have the potential to cause serious harm or death.

They highlight the potential weaknesses in how an organisation manages its fundamental safety processes; if a Never Event occurs, it usually indicates that national patient safety guidance or recommendations were not followed or implemented.

The concept was first introduced in 2008 and initially NHS trusts would receive a penalty cost if a Never Event happened. However, this was dropped in 2018 as the NHS tried to shift away from what it called ‘blame culture’.

Never Events must be reported and investigated to find out what went wrong and learn from any mistakes.

Examples of Never Events

Never Events are categorised into four main categories. These are listed below. The number indicates the number of cases reported in 2022/23.

Surgical never events

• Wrong site surgery (169)
• Retained foreign object post-procedure (96)
• Wrong implant or prosthesis (42)

Medication never events

• Wrong route of medication administration – i.e., oral meds given intravenously (16)
• Overdose of insulin due to abbreviations or incorrect device (6)
• Overdose of methotrexate for non-cancer treatment (1)
• Mis-selection of a strong potassium solution (1)
• Mis-selection of high-strength Midazadam during conscious sedation (1)

General never events

• Misplaced naso or oro gastric tubes and feed administered (31)
• Unintentional connection of a patient requiring oxygen to an air flowmeter (7)
• Transfusion or transplantation of ABO incompatible blood components or organs (6)
• Falls from poorly restricted windows (3)
• Chest or neck entrapment in bedrails (1)
• Scalding of patients (1)

Mental health never events

• Failure to install functional collapsible shower or curtain rails (1)

Why do Never Events persist?

Usually, Never Events happen because barriers are not strong or systemic enough to stop them. They are linked to factors like staff fatigue, performance targets, inadequate training and interruptions during tasks.

Healthcare is high risk by nature. But NHS trusts need to manage these risks more proactively to avoid Never Events from happening. Failing to do so means proven safety protocols and policies are overlooked at a human cost – avoidable injury to patients.

Last year, Never Events occurred at 142 NHS providers in the UK. Most of these experienced one or two Never Events, which in itself is a red flag that safety systems are not robust.

However, the three NHS providers with the highest number of Never Events were Royal Devon University Healthcare NHS Foundation Trust (10), Manchester University NHS Foundation Trust (9), and University Hospitals Birmingham NHS Foundation Trust (8).

Repeated failures show that lesson learning does not happen and more needs to be done to develop a culture that takes patient safety seriously.

Making a claim for Never Events

The physical and psychological effects of Never Events can stay with a patient for life. Often, patients are readmitted to hospital or require further surgery to fix these mistakes.

Amongst the most serious cases from last year’s data were four people who underwent a lumbar puncture intended for another patient, a thrombectomy of the wrong cerebral artery while treating a stroke patient, and a patient who had laser eye surgery on the wrong eye.

Last year’s data also shows that two women were left infertile when their ovaries were wrongly removed during surgery. Specialist medical solicitor Caroline Moore recently supported a clinical negligence claimant who experienced a similar situation in 2018 when part of her fallopian tube was unknowingly removed during removal of an ovarian cyst. This claimant was awarded £330,000 compensation.

Of the 78 cases of retained foreign object post procedure, a sixth involved a surgical swab. These retained objects can cause infection, adhesions, obstruction and sepsis. In 2021, specialist medical solicitor Miriam Bi supported the family of a man who died after a surgical swab was left in his body for 20 months following a Hartmann’s procedure for bowel disease. He sadly died and his daughter was awarded £20,000 compensation for her father’s estate.

And earlier this year, trainee solicitor Kelly Hunt assisted a client who was burnt during an MRI scan after clinicians failed to undertake the necessary pre-procedural checks and remove all ECG stickers. The oversight resulted in three burns to his torso and back underneath the ECG stickers. He was awarded £3,000 in compensation.

If you or a close family member have experienced a Never Event while being treated by the NHS, you may be able to bring a compensation claim. Our empathetic team of specialist medical solicitors can have vast experience in representing claimants and can support you through what can be a difficult period in your life. We offer Conditional Fee agreements, aka 'No Win No Fee' so you have nothing to lose by making an initial enquiry.