6 NHS patients a week affected by Never Events
In the past 4 years, more than 1,000 patients have suffered from clinical negligence so serious they are classified as Never Events by the NHS, according to analysis by the Press Association.
These events include the case of a patient whose life was put in danger when feeding tubes were mistakenly inserted into the patient's lung instead of their stomach.
The NHS insists that such events are very rare, affecting one in every 20,000 procedures. Despite these reassurances, the figures have prompted condemnation from the Patients' Association.
Putting patients lives in danger
The Press Association analysis revealed that 1,188 patients suffered never events since 2012.
Defined as "serious, largely preventable patient safety incidents that should not occur if the available preventative measures had been implemented," the incidents included:
- 400 patients who suffered wrong site surgery on the wrong side of the body, the wrong part of the body or, as in one reported case, on the wrong patient.
- 420 patients who had foreign objects left inside their bodies after surgery, including gauzes, swabs, rubber gloves, drill guides and scalpel blades.
- Patients who were given the wrong type of blood during transfusions, the wrong type of prosthetic or implant, or the wrong type or dose of drug.
Overall, there were 254 never events from April 2015 to the end of December 2015. From April 2014 to March 2015, there were 306 never events, and from April 2013 to March 2014, there were 338. In the previous year - from April 2012 to March 2013 - 290 never events were reported by NHS staff.
In 2014/15, Colchester Hospital University NHS Foundation Trust reported the highest number of never events, with nine recorded in total.
Duty to record Never Events
Hospital Trusts are required to publicly report the occurrence of Never Events within the services they commission on an annual basis.
A Trust that reports a never event is expected to investigate the incident so it can take action to prevent similar incidents in the future.
In 2013, the NHS commissioned a taskforce to investigate the number of Never Events occurring in hospitals across the country. The report led to the publication of a new set of national standards to support healthcare staff in preventing these avoidable mistakes.
Despite this, there has been no material reduction in the number of never events in recent years, as the Press Association analysis shows.
What actions can be taken?
Medical staff have a duty of care to ensure that patients attending for medical treatment are kept safe from avoidable harm. Even when the physical effects of a never event are less serious, the patient may suffer psychological harm when they realise that their care has fallen far short of the required standard.
The data analysed by the Press Association highlights the need to re-focus on the proper training and monitoring of staff to ensure patient safety. Never events are so called because they should never occur. The data suggests that more could be done to tackle these issues.