NHS Never Events report 1 April and 31 August 2023

NHS England recently published its provisional summary of Never Events reported as occurring in NHS Trusts in England between 1 April and 31 August 2023. Starr Thompson from our clinical negligence team reviews these latest statistics.

What are Never Events? 

‘Never Events’ are defined by the NHS as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.”  

The concept of Never Events is for organisations to learn from what happened and their occurrences, rather than to assign blame.   

NHS providers are encouraged to learn from mistakes. Any NHS trust that reports a Never Event is expected to conduct its own investigation, so that it can learn and act on the underlying causes. 

Types of ‘Never Event’ 

When data for the provisional report was extracted, there were a total of 151 serious incidents between 1 April and 31 August 2023 which met the definition of a Never Event. These were across 86 NHS trusts and other healthcare providers.   

These are categorised as follows: 

  • 80 incidences of wrong site surgery – 16 of which involved the wrong skin lesion being removed. 6 of these involved an injection into the wrong eye.  
  • 27 incidences of retained foreign object post procedure – 7 of which related to a surgical swab being retained. 
  • 14 incidences of wrong implant/prothesis – 5 of which related to the hip and another 5 related to the knee.  
  • 7 incidences of transfusion or transplantation of ABO-incompatible blood components or organs – 6 of which relating to the wrong blood being transfused to patients.  
  • 7 incidences of administration of medical by the wrong route. 
  • 10 incidences of misplaced naso or oro gastric tubes – 5 of these were the result of placement checks not being described or clearly described.  
  • 2 incidences of unintentional connection of patient requiring oxygen to an air flowmeter.  
  • 1 incidence of falls from poorly restricted windows. 
  • 1 incidence of failure to install functional collapsible shower or curtain rails. 
  • 1 incidence of scalding a patient. This was the result of a bowl of water for washing at the beside coming from a kettle.  
  • 1 incidence of overdose of insulin due to the wrong syringe. 

9 serious incidents during this period did not appear to meet the definition of a ‘Never Event’.  

Comparison to Previous Reports 

The provisional data for 2022/2023 confirmed 384 serious incidents between the period 1 April 2022 and 31 March 2023.  

These figures demonstrated a slight decrease in the number of Never Events since 2021/2022, when there were a reported 407 serious incidents between 1 April 2021 and 31 March 2022. However, 169 incidents still related to wrong site surgery. 

Based on the above previous data, the figures for 2023/2024 are therefore likely to double at the very least. 

Conclusion 

There are still a substantial number of entirely preventable mistakes being made by NHS Trusts causing serious injury to patients and in some cases death. The same fundamental errors appear to be repeated year after year, highlighting that more still needs to be done to learn from adverse incidents, change practice and prevent patients suffering unnecessary harm.   

Never Event Claims 

Morrish Solicitors’ medical negligence team specialises in never event claims.  

Contact us on 033 3344 9613 or  email [email protected]