Latest data shows potentially fatal 'never events' persist

20 September 2019

According to data obtained by the PA news agency hundreds of patients have suffered due to medical mistakes and errors so serious they should never happen. Some 621 of these so called “never events” occurred in NHS hospitals between April 2018 and July 2019. During that period nine patients a week suffered varying degrees of harm due to mistakes, oversights and errors that should have never been allowed to happen.

Many mistakes are potentially fatal

The figures show surgeons operated on the wrong body parts, amputated the wrong limb and left surgical tools inside patients. Two men were mistakenly circumcised, while a woman had a lump removed from the wrong breast. Several patients endured procedures that were intended for someone else or had the wrong blood type transfused.

Most recently Rebecca Sellers, an associate solicitor specialising in clinical negligence claims, has been instructed by a client who had surgery at the Queen Elizabeth Hospital, Birmingham in June 2019 to remove his left testicle, which was thought to be cancerous.

The surgeon removed his right testicle as opposed to his left, but didn’t realise the error until the histology reports confirmed that the right testicle was not cancerous. Our client had follow up appointments to confirm the mistake and list him for further surgery. He was transferred to a specialist at University College Hospital in London to see if his left testicle could be preserved, but this proved to be impossible and he underwent surgery to remove the remaining testicle in August 2019.

Regional variation in rate of “never events”

The PA report, based on figures obtained from NHS Improvement, are provisional but show that some NHS Trusts have higher error rates and more potentially fatal “never events” than others

  • Barts Health NHS Trust in London had the most errors (17) including eight cases of wrong site surgery
  • Walsall Healthcare NHS Trust had the next highest with 13 such recorded incidents
  • Guy’s and St Thomas’ NHS Foundation Trust and University College London Hospitals NHS Foundation Trust had 12 such episodes each
  • University Hospitals Birmingham NHS Trust recorded 11 such “never events”

CQC report

A report on errors from the Care Quality Commission (CQC), which called for a change in safety culture across the NHS, found that “never events” continue to happen ‘despite the hard work and efforts of frontline staff’. Sarah Corser,  senior associate in Shoosmiths medical negligence team, commented:

‘The CQC’s earlier report confirmed that, in many cases, these entirely avoidable injuries to patients result from a combination of administrative, training, operational and managerial failures as well as simple human error.  While these cases are thankfully very rare, never should mean never. It is important that the NHS takes the CQC’s suggestions on board and continues to promote a culture of openness and transparency in disclosing the frequency of these errors. The object should not be to apportion blame, but to learn lessons and prevent such events from happening at all.’



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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