Never Events is the term used in the NHS to describe entirely preventable serious incidents that potentially or actually cause harm to patients or jeopardise patient safety.

Never events are patient safety incidents that could have been prevented had healthcare providers properly implemented existing national guidance and safety recommendations. They include things like wrong site surgery and retained foreign objects following surgery. Any Never Event is unacceptable.

The term ‘Never Events’ was first introduced in 2001 by Ken Krizer MD, former CEO of the National Quality Forum in the United States of America.

The NHS in England is one of the few healthcare systems in the world that openly reports on patient safety incidents. Provisional Never Events data is published by the NHS every month.

Never Events reported between 1st April and 31st August 2018

Provisional figures published by the NHS on Never Events between 1st April 2018 and 31st August 2018 report a total of 209 entirely preventable serious incidents. The figures include 83 occurrences of wrong site surgery, 48 incidents of a retained foreign object post procedure, 26 wrong implants/prosthesis and 23 separate incidents of patients being connected to an air flowmeter rather than oxygen.

Also included were a small number of incidents of medication being given by the wrong route (e.g. oral medication given intravenously) and two incidents of medication overdose with methotrexate for non-cancer treatment.

These are worrying statistics for patients. At a time when the NHS is under increasing pressure, patients need to be more vigilant than ever to ensure they are receiving safe healthcare.

Why do Never Events happen?

Never Events shouldn’t happen, but tragically they do. The common denominator in almost all Never Events is the human factor. If all safety protocols were carried out to the letter, Never Events wouldn’t occur.

Writing in 2016, Consultant Colorectal Surgeon, Mr Andrew Miles said ‘human factors can confound the operating team so that in about 1 in 30,000 operations, an error is made.” Why? Quite simply surgeons are under pressure like never before.

The increasing work pressure can be seen across the spectrum of NHS staff from surgeons, anaesthetists, nurses and paramedics to healthcare assistants, ward clerks and porters. Mr Miles says that interruptions and distractions can lead to errors and these can’t be predicted.

A report in The Guardian at the end of last year revealed the NHS as an ailing service under severe strain. Saffron Cordery, NHS Director of Policy and Strategy and Deputy Chief Executive NHS Providers writes, “I have worked in the NHS for 45 years and never have I seen so many staff work under such pressure for so long.

“If we’re to deliver the high quality patient care we all want, we must change our approach to NHS workforce so that we have the right number of staff, with the right skills, in the right place.”

What is being done to prevent Never Events?

The Care Quality Commission (CQC), the independent regulator of health and social care in England, recently carried out a review of the issues contributing to the occurrence of Never Events in NHS trusts in England.

In collaboration with the NHS, the CQC have visited the sites of a number of NHS Trusts, held focus groups with frontline NHS staff, interviewed patients and worked with experts from safety critical industries.

Emerging themes likely to result in recommendations for good practice include:

  • Review the autonomy of clinicians which allows them to deal with complex situations and provide the right treatment. The CQC has highlighted the fact that clinicians can be compromised under pressure and this has implications for safety protocols and policies.
  • Embedding safety may need to be a fundamental part of every NHS role, which has implications for training.
  • The need for Trusts to manage risks more proactively.

Surgeon, Mr Andrew Miles says some of the onus is on the individual staff member. Individuals across the board in the NHS need to be able to say no when they are asked to do something under pressure without adequate safety checks. This requires team training in communication and awareness of human factors.

Never Events and negligence – making a claim against a hospital

If you have been the victim of a Never Event at any NHS hospital you may be able to make a claim for compensation. However, it will depend on the event and the extent to which you have been affected. Not every Never Event is negligent. You will need to prove that someone else was responsible for the incident and that you were harmed in order to make a claim for compensation.

For a successful claim in clinical negligence, you will need to prove the following:

  1. The doctor or clinician who treated you had a duty of care not to cause injury
  2. That duty of care was breached
  3. This breach of duty caused or contributed to injury or loss
  4. Damages or financial loss has resulted from the harm caused (i.e. loss of earnings)

It is extremely important to seek legal advice if you feel you have suffered as a result of clinical negligence caused by a Never Event in the NHS. For more advice on clinical negligence and taking legal action, see the Citizen’s Advice guidance here.

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