The NHS has published its latest data on the occurrence of never events – serious, and largely preventable patient safety, incidents that are so shocking they should never be allowed to occur.

The report states in its opening paragraph 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.’  It is worrying then that there were 314 never events in just a nine-month period up to December 2021.

Of those 314 incidents there were some alarming examples of mistakes that were made. This includes surgery carried out on the wrong part of the patient’s body and myriad operations which were intended for another patient.  Meanwhile there were 75 examples of foreign bodies, such as specimen bags, scalpel blades, swabs and parts of surgical instruments, being left inside the patient.  In addition, 38 patients had the wrong implant or prosthesis fitted during surgery. 

Manchester University NHS Foundation Trust reported 10 incidents involving a never event, the highest number for a single trust in the country.  Other trusts reporting high number were Leeds Teaching Hospitals, East Suffolk and North Essex NHS Foundation Trust and Liverpool University Hospitals. 

In a large number of these cases, the patient will have suffered harm.  The data doesn’t set out the extent of the harm caused for each patient but some may have lost their lives as a result of these entirely preventable incidents. Others will have required additional treatment and will likely have lost faith and trust in the NHS and its clinicians, having experienced such appalling errors.     

In our specialist clinical negligence department here at JMW we act for clients who have suffered clear and avoidable errors such as these. Examples of cases involving never events we have recently dealt with include a patient who had surgery on the wrong part of his back and another extremely tragic case when a patient died after his lungs were washed with cleaning fluid instead of saline.  One of our clients had part of a surgical instrument left in his spine during surgery. 

We see first-hand the devastating impact these events can have on a patient and their family and, with the increasing pressure on an over-stretched and under-resourced NHS, it is concerning to think that the number of never events will only increase.  

However with strong patient safety guidelines that, crucially, are followed, these terrible events can be avoided. Effective management and training of staff can see this achieved through the most basic of steps.

I don’t believe there is ever an excuse for a never event to happen and reducing, or even eliminating, their occurrence would lay the foundations for an NHS that is more consistently safe.