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What are 'Never Events'?
NHS Improvement defines Never Events as ‘serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations’.
NHS Improvement has produced guidance for providers of NHS care to tailor their policies and procedures to minimise the risk of Never Events occurring, extending the potential for improvements to patient safety beyond the department or type of procedure involved.
The latest Never Events List produced by NHS Improvement in January 2018 includes the following:
- 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 incorrect device
- Overdose of methotrexate for non-cancer treatment
- Mis-selection of high strength midazolam during conscious sedation
- Failure to install functional collapsible shower 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
NHS Improvement monitors all Serious Incidents reported on the StEIS System which were designated by their reporters as Never Events. The latest statistics, published on 28 March 2019, reveal that there were 461 reported Never Events between 01 April 2018 and 28 February 2019. This represents a sizeable increase from the previous report for the period 01 April 2017 to 31 January 2018 when 405 Never Events were reported.
It is accepted that a single Never Event acts as a red flag that an organisation’s systems for implementing existing safety advice/alerts may not be robust, sometimes pointing to systemic failures which may, in extreme cases, merit a claim under the Human Rights Act 1998.
It is notable that our local Trusts appear in the latest statistics. The Pennine Acute Hospitals NHS Trust reported 3 Never Events, Tameside and Glossop Integrated Care NHS Foundation Trust appears in the list twice, and Manchester University NHS Foundation Trust is listed 4 times. The majority of the Never Events reported by these Trusts involved wrong site surgery and retained foreign objects post-procedure.
From a medical negligence claim viewpoint Never Events are usually indefensible and victims should seek advice from a specialist medical negligence solicitor on whether they are entitled to compensation in relation to the treatment that they have received.
If you feel that you have a claim and would like advice please complete the contact form and a medical negligence solicitor will call you back for a free no-obligation consultation. Alternatively, call us on 0800 731 1874.