Provisional summary of Never Events – April 2023 – March 2024
According to NHS England, Never Events are defined as serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. Never Events are different from other serious incidents as the overriding principle of having the Never Events list is that even a single Never Event acts as a red flag that an organisation’s systems for implementing existing safety advice/alerts may not be robust.
NHS England has published its provisional summary of Never Events reported to have occurred between 1 April 2023 – 31 March 2024. Associate Solicitor in the medical negligence team, Oongah McCurry, takes us through this report and compares it against the previous one.
During this period, a total of 370 Never Events were reported. These were categorised as follows:
- 179 wrong site surgeries, including 52 wrong skin lesions being biopsied or removed; 35 wrong side/site procedures; and 6 procedures performed on the wrong patient
- 81 retained foreign objects post-procedure
- 37 wrong implant/prosthesis, including 10 lens, 9 hips and 8 knees
- 22 Misplaced naso or oro gastric tubes
- 20 instances of administrations of medication via the wrong route, including 16 occasions of oral medication being given intravenously
- 10 transfusion or transplantation of ABO-incompatible blood components or organs
- 10 overdoses of insulin
- 3 cases of patients being connected to air rather than oxygen
- 3 overdoses of methotrexate for non-cancer treatment
- 2 mis-selections of a strong potassium sodium
- 1 scalding of a patient
- 1 fall from poorly restricted windows
- 1 failure to install a functional collapsible shower or curtain rail.
Trusts reporting the most Never Events in 2023/2024
Out of the 229 NHS Trusts in England, 136 reported at least one Never Event between 1 April 2023 and 31 March 2024.
The Trust reporting the most Never Events during this period was the University Hospitals Birmingham NHS Trust with 11 Never Events; while University Hospital Southampton NHS Foundation Trust; St George’s University Hospitals NHS Foundation Trust; and The Newcastle Upon Tyne Hospitals NHS Foundation Trust, each reported 10 Never Events.
Comparison to previous reports
The provisional data for the period 1 April 2022 – 31 March 2023, shows 384 Never Events were reported in England during that time. These included 169 wrong site surgeries; 96 retained foreign objects after surgery; and 42 wrong implants/prosthesis.
Although these figures show a slight reduction in the number of Never Events in 2023/2024, there are still clearly too many incidents of patients coming to unnecessary and avoidable harm. These figures do not take into account the other instances of serious and avoidable harm that occur as a result of negligent medical treatment which do not fulfil the definition of a Never Event.
The provisional data for the period 1 April 2024 – 31 July 2024, already shows that 79 Trusts in England have reported at least 1 Never Event during this period, with 120 serious incidents overall having been reported that appear to meet the criteria to be classified as a Never Event. These include 12 wrong skin lesions being removed or biopsied; 37 retained foreign objects post-surgery and 12 wrong implants/prosthesis. So far, the Leeds Teaching Hospitals NHS has reported the most Never Events at four.
At Morrish Solicitors LLP, we have a dedicated Medical Negligence Team who will be happy to assist you in pursuing a claim if you have suffered avoidable injury as a result of medical negligence. Call 033 3344 9613 or email [email protected].
Author: Oonagh McCurry, clinical negligence.
