23 February 2016
More Than 1,100 Patients Suffered Never Events in the Past Four Years
More than 1,100 patients have suffered from serious and wholly avoidable clinical errors in England's hospitals over the past four years, according to analysis by the Press Association, but is this the full story?
The so-called ‘never events,’ which the NHS define as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures had been implemented,” have included a woman having her fallopian tubes removed instead of her appendix.
The Press Association revealed that more than 400 patients suffered what is known as ‘wrong site surgery’ (WSS), which encompasses all surgical procedures performed on the wrong side or site of the body, wrong body part, and even surgery performed on the wrong patient.
In addition, more than 420 patients had ‘foreign objects’ accidentally left inside their bodies post-surgery. Foreign objects include any items that should be subject to a formal counting or checking process both before and during surgery. They include swabs, gauzes and needles as well as equipment such as scalpel blades and drill guides.
Some patients suffered potentially fatal clinical errors such as having feeding tubes mistakenly put inside their lung instead of being correctly fed into their stomach. Others were given the wrong type of implant, blood type or joint replacement, and some were even mixed up with other patients.
According to data published by NHS England, between April and the end of December 2015, there were 254 never events. From April 2014 to March 2015, there were 306 never events, while 338 occurred between April 2013 and March 2014. Between April 2012 and March 2013 there were 290 recorded.
Everyone agrees that never events should simply never occur, but is there a bigger story behind the headlines? Are never events correctly recorded and reported by all Trusts or just by those who are more transparent than others and those who fulfil their obligations under the Duty of Candour?
If a Trust is working under a financial deficit would they report all never events knowing that if they do so they will be financially penalised? What progress has or has not been made by the NHS to learn from never events so as to ensure that they do not happen again? Is the current system of reporting adding or hindering learning on patient safety issues?
The number of basic avoidable mistakes obviously raises serious concerns about NHS care standards and patient safety. Never events are potentially life-changing errors which should always be avoided through proper training and monitoring as well as the use of well-established safety measures. But what is the NHS actually doing about them to ensure that patient safety is improved and will we just be reading similar headlines in 12 months’ time?
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