What are ‘‘never events’’?

When medical care goes wrong, understandably patients and their families want to understand what happened and to be able to seek redress. In clinical negligence claims, the remedy will primarily be compensation for injuries caused and losses incurred – but for many patients, what’s of equal (if not more) importance to them is that healthcare professionals learn lessons so that mistakes are not repeated.

The NHS says it wants to learn from mistakes and since 2015 has published annual data on some of the most serious errors in care, which they term ‘‘never events’.’

These are “serious, largely preventable patient safety incidents that should not occur”. The list of what is classed as a never event includes operating on the wrong part of the body, misplacing a feeding tube, and leaving an object inside a patient during surgery. Evidently, these are not only extremely serious, but also, the NHS acknowledges, completely avoidable events that when appropriate procedures are followed should not happen.

Except they do – the specialist medical negligence team at JMW is frequently contacted by patients and families who have been harmed by ‘‘never events’’. Some have been left with lasting physical damage, others have a loved one who has tragically died,  but all have suffered a psychological scar due to the shocking nature of the mistake. And ‘‘never events’’ happen more frequently than anyone would like to see. According to the latest data published, between April 2022 and January 2023, 384 ‘‘never events’’ were reported in England (with separate data recorded in Wales). The logic behind collecting such data is, of course, to assist with learning and prevention. However, it seems to me that the data just shows that lessons are not being learned as, thus far, never event reporting does not appear to have significantly reduced their occurrence.

That is despite the list of what is categorised by the NHS as a ‘never event’ being reduced in 2018 so that there are now fewer incident types being tracked. For example, while wrong level spinal surgery used to be included in the data set, it no longer is, yet most of us would have thought such a mistake should not happen with proper care. It is certainly a mistake that could have serious consequences for the patient affected, and I have no doubt that such patients would want lessons to be learnt as a result.

Is ‘never event’ reporting an effective tool in improving patient safety?

When the concept of ‘never events’ was introduced in England & Wales following a governmental review in 2008, then Prime Minister Gordon Brown prefaced the report by saying that one aim of the entire review was to ‘focus on prevention’. This is obviously what we would all want the focus to be, but it seems to me that the way this concept has evolved over time has arguably become more about institutional naval gazing than improving patient safety.

There is little evidence that patient safety has improved and the restriction of what is considered a ‘never event’ can surely only limit, rather than encourage learning and improvements in patient safety?

Not only that, to be included in the ‘never event’ list, the NHS must already have implemented guidance on the issue that arises, meaning that in theory, robust measures are already in place to prevent things going amiss.

This seems to me to create a chicken and egg scenario – those mistakes happening, in part because there are not patient safety protections in place won’t be deemed a ‘never event’, meaning many patient safety incidents are not caught by this reporting system.

As to the issue of what happens once a ‘never event’ is identified, the NHS is somewhat vague; the ‘never event’ policy states that all occurrences must be analysed and “Leaders must then ensure that actions which measurably reduce the risk of recurrence are taken.” However, there is no set pathway to follow and no monitoring or follow up to ensure that Trusts are held accountable. For example, the framework does not say that every time surgery is performed on the wrong part of someone’s body, staff must undergo training. Nor does it say that once a ‘never event’ is reported, a trust must take specific steps to put things right for the future. It relies largely on trust leadership to ‘do the right thing’, but in an overstretched system that is struggling with general healthcare provision, we have seen that this does not always happen -  lessons are not learnt or improvements made.

Initially, NHS trusts under whom ‘never events’ happened could be fined by commissioners, but this was dropped in 2018 in a bid to avoid ‘a blame culture’, but there is a difference between blame and accountability and in my view those making avoidable mistakes should be held accountable in some way.

What should be done?

In my view the above suggests that the ‘never event’ system in this country needs reform.  My proposal is that there needs to be a suite of consequences, such as:

1.    Revisiting financial penalties

The idea for reporting on ‘never events’ came from an equivalent practice in the USA’s private health sector, whereby payment for treatment is withheld by insurers when serious, preventable events occur. Obviously, that is not possible in the same way with the NHS.

However, fining trusts for ‘never events’ was at least one tangible way of holding them to account prior to 2018 and currently they are not held to account at all. So, it may be worth revisiting this.

Of course, fining alone is unlikely to change poor practice. We know from clinical negligence practice that the NHS paying out money when found liable in individual claims does not necessarily lead to the review of errors or enactment of preventative measures we would all hope it would.

2.    Publication of numbers and severity of ‘never events’

Currently, data is published on how many ‘never events’ occur each year in each NHS Trust; however, we do not get to see what category of ‘never events’ are happening where. For example, are ‘wrong blood transfused’ episodes more common in Bedfordshire or Bolton? And is there a trend of one Trust repeating the same types of incident year on year?

Publishing the number of ‘never events’ for each trust more widely, with segmented data, and in any easily digestible format so that the different trusts, and more importantly their patients, can see where they rank in comparison to other trusts would be useful, especially if information on the severity of harm was available. In the USA, for example, Minnesota’s most recent report included details of the severity of harm per ‘never event’, so you can see exactly how many caused either serious injury or death.

3. Regulation, monitoring and education

In my view, the ‘never events’ data should be used by the NHS’ regulatory bodies to identify those trusts which are failing to make improvements and action should be taken by those bodies to improve policies, procedures and education in those trusts.

4.    Widen the definition of ‘‘never events’

To effectively improve the safety of patients I believe that the scope of what is classed as a ‘never event’ should be broadened (as it is for  ‘Adverse Health Event’ in the US) to include the sort of events that the general public would expect to be avoided. In the US, that  includes pressure sores, maternity and neonatal injuries, and inaccurate test results. It is arguable that these injuries and others should be added to the list of ‘never events’ in England & Wales.

We represent patients who have experienced clinical mistakes that have been life-changing. For example, our clients have suffered second-degree  burns during surgery, died  after being prescribed the wrong medicine, or in another sad case, died after receiving a highly dangerous dose of an anti-psychotic that should never been prescribed in the first place. None of these events should have happened, and yet none of them would currently be recognised as ‘never events’ under NHS criteria.

To me, what the data excludes, then, is even more concerning than the hundreds of incidents it includes.

5. Focus on the effect of those ‘never events’

What the data collected currently does not tell us is the human experience behind each tragic case - how have people been affected by experiencing such grave errors in care? I believe that that is where the focus should be.

When you read the published tables you see that one patient was scalded from hot bath water in 2022; another had laser treatment to the wrong eye, and two more mistakenly had their ovaries removed. Those are all life-changing injuries, yet the data can be skimmed over without any thought being given to the pain suffered, the long term effects on those patients, the misery caused to them, the psychiatric impact on patients and their loved ones, and the wider effect on their lives, including the further medical treatment needed, the levels of care required, the need for therapy, their time off or inability to return to work afterwards.

I would like to think that, if like us, those responsible for patient safety saw the effect of these wholly avoidable events on the people harmed then perhaps they would take them more seriously and make concerted efforts to reduce that harm.

Blog by Chloe Wynne.