The NHS defines never events as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures had been implemented”.
The updated 2014 Never Event list was expanded by the NHS to 25 areas, ranging from operating on the wrong body site, retained products (such as leaving surgical swabs/instruments in a patient); through to not monitoring/responding to oxygen levels, which can be fatal.
The NHS provides this information to try and improve risk management at all levels, and to share effective examples of incidents, but unfortunately we still see occasions of such errors arising. With effective training and monitoring these incidents can often be prevented through simple measures, like counting all swabs/instruments before an operation and then at the end to ensure that they are the same. Standards can only be effective if there are the right resources and time to enable patient safety to be maintained.
Unfortunately when clinical errors do occur, they can be life changing, and the increased care needed for any patient places a greater resource issue on the NHS at an already difficult time.
With the NHS itself estimating that there are around 12,000 avoidable hospital deaths per year and more than 10,000 serious incidents, including 338 "never events", time and training has to be paramount to address such occurrences.
The NHS can provide world leading care but unfortunately we still see repeated errors arising and missed opportunities to reduce risk and learn from mistakes, which can unnecessarily put patients in danger. Through cases and training, where possible, we work with the NHS to ensure effective change for risk management to prevent incidents happening to other patients and help improve standards.
Tim Deeming is a Senior Clinical Negligence Solicitor at Slater and Gordon Lawyers UK.
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