A report by the Care Quality Commission (CQC) addressing serious events in NHS care has recently been published for the period 2017 to 2018. The analysis primarily focuses on care received in NHS hospitals with over 344 cases arising from what are considered by healthcare professionals to be ‘never events’.

What is a never event?

The NHS describes never events as being ‘serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers’. Therefore, in a nutshell, a never event is an incident that should never occur in healthcare practice, and if it does, this amounts to a failing in the patient’s care by the NHS.

Every year, the NHS publishes a list of what is deemed to be a never event. At present, 15 incidences are classified under this description as follows:

  • wrong site surgery
  • wrong implant / prosthesis
  • retained foreign object post procedure
  • mis-selection of a strong potassium solution
  • administration of medication by the wrong route
  • overdose of insulin due to abbreviations or an incorrect device
  • overdose of methotrexate for non-cancer treatment
  • mis-selection of high strength midazolam during conscious sedation
  • failure to install functional collapsible showers or curtain rails
  • falls from poorly restricted windows
  • chest or neck entrapment in bed rails
  • transfusion or transplantation of ABO-incompatible blood components or organs
  • misplaced naso or oro-gastric tubes
  • scalding of patients
  • unintentional connection of a patient requiring oxygen to an air flowmeter.

Report findings

It is worrying that six cases in the Surrey area in an eight month period had the potential to cause significant harm or death to the patients concerned. The incidences included patients being given incompatible blood or organs in a transfusion or transplantation, surgeons performing surgery on the wrong patient or wrong body part and surgical instruments being left inside patients following surgery.

According to the report, the ‘most common’ type of never event occurring across England was surgery being performed on the wrong person, or on the wrong part of the body. Recently it has come to light that healthcare professionals at Leicester Hospital mistakenly carried out a circumcision procedure on a patient when he was only meant to be having a cystoscopy, a far less invasive investigative procedure which is performed to look inside the bladder.

Naomi Holland, an associate in the clinical negligence team at Penningtons Manches, comments: “The NHS is keen to prevent these events which cause entirely unnecessary harm. If such an incident occurs, the hospital should take immediate action to investigate the circumstances. Unfortunately, from our experience, this is not always the case. We have encountered many instances of never events and it is surprising that they continue to be a problem despite the term being first introduced in 2001.

“Pressure, lack of resources and time, and failure to undertake the appropriate checks have been described as key factors behind the problem. It is however clear from the CQC report that greater efforts need to be made to minimise these incidences because the harm caused to patients and their families can potentially be significant.”