'Never Events’ and the possible reasons behind them | Davis Blank Furniss

Over the past few weeks, NHS England has been the subject of press coverage regarding so called NHS ‘Never Events’.

The NHS categorises a Never Event as: a serious incident that is wholly preventable, as there is guidance or safety recommendations that provide strong systemic protective barriers and these should have been implemented by all healthcare providers.

There are a number of categories the NHS uses in relation to Never Events. These include; wrong site surgery, misidentification of patients, wrong implant/prosthesis and escape of a transferred prisoner. NHS England publishes data every month about the number (and type) of Never Events that happen. This information is available to the public via its website.

The Press Association analysed the most recent Never Events data for the period from April 2012 to December 2015 and found there were over 1,100 incidents categorised as Never Events. These included; patients being given the wrong type of blood, the wrong drugs and the wrong types of implants. Shockingly, last year one woman had her ovaries removed when they were meant to be conserved. There have also been hundreds of examples of ‘objects’ (such as scalpels) being left in patients after operations.

Patients – of course – have to be prepared for some risks but the NHS itself admits that these events should never have happened. As Katherine Murphy, chief executive of the Patients Association, recently said: ‘It is a disgrace that such supposed ‘never’ incidents are still so prevalent. She added: How are such basic, avoidable mistakes still happening? There is clearly a lack of learning in the NHS.’

Unfortunately, it appears that the number of Never Events have risen in recent years. Analysis carried out by the BBC in 2013 showed that in a similar four year period (2009 – 2012) there were 762 Never Events. This compares with the recent figure of over 1,100. Although the most recent figures are still provisional it appears that the number of Never Events has increased.

In response to the recent analysis an NHS England spokesperson said: ‘One “Never Event” is too many and we mustn’t underestimate the effect on the patients concerned.’


‘To better understand the reasons why, in 2013 we commissioned a taskforce to investigate [Never Events], leading to a new set of national standards being published last year specifically to support doctors, nurses and hospitals to prevent these mistakes.’

However, preliminary figures for the period March 2015 to December 2016 show that the number of Never Events is static. The fact that these Never Events are still happening with such regularity is concerning and other recent news indicates that the NHS will struggle to implement the procedures necessary to eliminate them.

Figures published recently show the NHS in England has overspent by £2.2bn for the first three quarters of the current financial year. NHS Trusts in England are likely to find themselves under increasing pressure to spend within their budgets and may have to cut corners to meet targets.

It has also been revealed despite the recent overspend, that more than two-thirds of NHS Trusts and health boards are actively trying to recruit staff from abroad as they struggle to cope with a lack of qualified staff. Data from a BBC Freedom of Information request showed that on 1st December 2015, the NHS in England, Wales and Northern Ireland had more than 23,443 nursing vacancies – equivalent to 9% of the workforce.

It appears that a factor in the failure of the NHS to reduce the number of Never Events could be the inability to hire the necessary qualified staff. This is worrying, and with the added pressure of the increasing budget deficit, it could be increasingly difficult for NHS Trusts to justify hiring additional staff.

Despite Never Events being easy to avoid there are still approximately 300 patients a year who are victims. This obviously does not take into account of the incidents where mistakes are made but the mistake falls short of ‘Never Event’ status. Therefore, it’s clear that a large number of patients are receiving treatment that falls significantly below the standard they should receive.

If you or someone you know thinks they may have been the victim of a Never Event or any other problem during a medical procedure, please contact our Clinical Negligence team on 0161 832 3304.


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