Hundreds of incidents so serious they should never happen recorded in NHS

Some 314 'Never Events' were recorded over nine months revealing a worrying list of blunders including a procedure on the wrong side of the brain

Rebecca Flood
Friday 10 February 2017 18:27 GMT

Hundreds of incidents so serious they should "never" happen have taken place in the NHS in just nine months.

Fresh figures from the NHS have revealed the frequency of so-called "Never Events" ranging from medical equipment being left inside patients to procedures on the wrong side of the brain.

Statistics published by NHS Improvement outlined 314 incidents took place between April 16 and December 31 last year – more than one a day.

Referred to as Never Events, the NHS described them as “serious, largely preventable” safety breaches, and differ from other grave events as just “even a single Never Event acts as a red flag”, highlighting potentially fatal failings.

The figures come as Jeremy Hunt comes under renewed pressure of the buckling state of the health service.

In the latest of a strong of bad headlines, it has emerged that a total of 82,730 planned operations were cancelled at the last minute for non-clinical reasons – a jump of 16% on 2015, and a third higher than in 2010.

The findings come a day after separate data showed the NHS in England was performing at its worst-ever level against a range of targets, including A&E admissions, cancer referrals and people forced to wait on trolleys.

The most common "Never Event" was surgery or an operation on the wrong anatomical part, including one case where medics began working on the opposite side of the brain.

Some 31 people discovered the wrong tooth, or teeth, had been tampered with, and surgery commenced on the wrong, rib, hip, leg, elbow, buttock, shoulder and a host of other body parts.

Several patients had completely unnecessary procedures in a case of mistaken identity, undergoing lumbar punctures, laser eye treatment and one person who ended up with a heart monitor under their skin intended for another person.

Foreign objects left behind after a procedure was the next highest incident, with 75 recorded cases.

Cotton buds, ribbon gauze, part of a catheter, screw tabs and throat swabs and a host of other equipment were all found internally.

Part of surgical forceps, part of a drill – which was not noted to be missing at the time – a drill guide, a surgical needle and 23 vaginal swabs were later discovered to be inside patients.

And the data also includes six cases which occurred prior to April, including two patients who had medical equipment still inside them from a procedure in 2012, and another dating from 2014.

There were 38 occasions when people were given the wrong implant or prosthesis, 33 incidents of people whose medicine was administered incorrectly, including 16 times oral medication was given intravenously and one occasion where the “epidural and intravenous medication were mixed up and both given via the wrong route”.

In 21 cases tubes inserted into the nose and mouth were misplaced.

On three occasions patients were given an overdose of methotrexate for non-cancer treatment, which side effects include jaundice, blistering and peeling skin and blurred vision.

And twice an overdose of insulin – caused by abbreviations or an incorrect device – were recorded.

One person was given the wrong blood type in a transfusion, and another received potassium instead of saline.

The list also details one person who burnt their feet while soaking them in a bowl of scalding water.

Not just medical mistakes, other practical incidents occurred including two patients who managed to fall out of the building due to “poorly restricted windows”, two people managed to trap their neck or chest in bed rails, and another two incidents were recorded where a collapsible shower curtain failed to do so.

The litany of mistakes were described as inexcusable by Katherine Murphy, chief executive of the Patients Association.

She said: "We are concerned by recent data published by NHS Improvement. Never-events are precisely that, events that should never, ever happen.

“The fact that they are occurring should ring alarm bells in Trusts, with Clinical Commissioning Groups, NHS England and the Department of Health.

“There are no excuses for failing to follow medical protocols as it could be the difference between life and death.

"Whilst patients and the public understand that medical professionals and support staff are under pressure and have increasing workloads, this is not an excuse for allowing never-events to occur.

“Ultimately, most patients will be anxious or at any rate, unwell, and so they should not have to have the added stress and burden of worrying about issues like never-events."

The list also broke down how many events happened at each NHS Trust, with the trust seeing the highest rate of incidents Barts Health NHS Trust, in London.

Dr Alistair Chesser, medical director at the Trust, said they were committed to improving safety and had employed more nurses and providing extra training for staff.

He said: “We wholeheartedly apologise to our patients who have suffered from never events at our hospitals.

“In a typical year we care for over 270,000 inpatients and over 1.4 million outpatients cases, with never events happening rarely – however, we are clear that each is totally unacceptable.”

Newcastle Upon Tyne Hospitals NHS Foundation Trust came second with seven incidents, but the Trust stressed none of those affected died or suffered serious harm.

A spokesman said: “The Newcastle upon Tyne Hospitals NHS Foundation Trust performs circa 80,000 surgical procedures annually and includes a Dental Hospital.

“The incidence of never events within this Trust, based on the above study, is therefore considerably below what would be expected of an organisation of its size and complexity.”

In joint second place was County Durham and Darlington NHS Foundation Trust which also reported seven incidents, the majority being surgery on the wrong site.

A spokesman said: “While there are risks associated with healthcare one never event is too many and by definition they should not happen and if they do we take this extremely seriously as do our clinical teams.”

They added they had implemented a number of measures and actions to ensure lessons were learned from previous Never Events.

In third place with six cases was Guy's and St Thomas' NHS Foundation Trust, which has launched a major patient safety campaign, Always Safe, which aims to raise awareness of serious incidents and encourage feedback.

A spokesman said: “Guy’s and St Thomas’ takes never events very seriously and all incidents reported by our staff in 2015/16 have been fully investigated.

"We encourage reporting as part of a ‘no blame’ culture and have responded openly and pro-actively to these incidents to ensure lessons are learnt and shared across our organisation.”

Wrightington, Wigan and Leigh NHS Foundation Trust, while only reporting one Never Event, saw a patient get their neck or chest trapped in the bed rails.

A spokesman confirmed they did not suffer “moderate or long term harm” as a result, adding: “Immediate actions were taken to mitigate the risk of a re-occurrence.

“An investigation and action plan has been completed and submitted to the Clinical Commissioning Group.”


Dr Mike Durkin, NHS National Director of Patient Safety, praised the transparency of the NHS, saying it as important for staff to continue being “open and honest” when things go wrong.

He said: “All patients deserve high quality, safe care.

“We expect organisations to investigate and learn from mistakes, and the fact that more and more NHS staff take the time to report incidents is good evidence that this learning is happening locally.

“To support the prevention of Never Events we recently published a set of new National Safety Standards for Invasive Procedures, and all relevant NHS organisations in England have now been instructed to develop and implement their own local standards in line with these national principles.”

He pointed to the definition of Never Events which was changed in 2015, adding new criteria and making comparisons with previous years ineffective.

The figures are subject to change one local investigations are completed.

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