Never Events

In Brief:-

Alex Tengroth looks at the latest ‘Never Event’ data published by the NHS nationally, covering the period April 2016 to March 2017, with a specific focus on how it applies to the various NHS Trusts in the South East.

In Detail:-

‘Never Events’ are serious, largely preventable patient safety incidents that should not occur if existing national guidance or safety recommendations have been implemented by healthcare providers.

The NHS has been keen to track the occurrence of ‘Never Events’ since April 2009 and they publish their data annually. The latest data, for the period April 2016 to March 2017, was published (provisionally) on 16th June 2017.

All NHS Trusts and Clinical Commissioning Groups (CCG’s) reported the number of ‘Never Events’ which had occurred at their institutions within the following categories:-

  1. Wrong site surgery;
  2. Retained foreign object post-procedure;
  3. Wrong implant / prosthesis;
  4. Wrong route administration of medication;
  5. Misplaced nasogastric / orogastric tube;
  6. Overdose of insulin due to abbreviations or incorrect device;
  7. Overdose of methotrexate for non cancer treatment;
  8. Chest or neck entrapment in bedrails;
  9. Falls from poorly restricted windows;
  10. Failure to install functional collapsible shower or curtain rails;
  11. Scalding of patients;
  12. Mis-selection of a strong potassium containing solution; and
  13. Transfusion or transplantation of ABO incompatible blood components or organs.

Looking at the latest data, there were a total of 424 ‘Never Events’ reported during this period, and these were broken down into each of the above categories, as follows:-

  1. 178 – the most frequent being surgery to the wrong tooth;
  2. 109 – 53 of which referred to retained swabs;
  3. 49 – 18 of which referred to incorrect knee implants;
  4. 40 – 19 of which referred to oral medication given intravenously;
  5. 26 – all of which referred to misplacement of a nasogastric tube into the respiratory tract and feed being administered;
  6. 6;
  7. 5;
  8. 3;
  9. 3;
  10. 2;
  11. 1;
  12. 1; and
  13. 1.

These 424 ‘Never Events’ were reported by a total of 184 NHS Trusts and CCG’s, such that the average number reported per institution equates to 2.3 Never Events.

Of those Never Events’ listed above, the following were reported by NHS Trusts in the South-East (excluding London):-

  • Brighton & Sussex University Hospitals NHS Trust reported a total of 5 Never Events (4 ‘retained foreign object post-procedure’, 1 ‘scalding of patients’).
  • Dartford & Gravesham NHS Trust reported a total of 2 Never Events (1 ‘retained foreign object post-procedure’, 1 ‘wrong implant / prosthesis’).
  • East Kent Hospitals University NHS Foundation Trust reported a total of 3 Never Events (all 3 were ‘wrong site surgeries’).
  • East Sussex Healthcare NHS Trust reported a total of 2 Never Events (1 ‘wrong site surgery’, 1 ‘wrong route administration of medication’).
  • Kent Community Healthcare NHS Trust reported a total of 1 Never Event (‘wrong site surgery’).
  • Maidstone & Tunbridge Wells NHS Trust reported a total of 4 Never Events (2 ‘wrong site surgery’, 1 ‘wrong implant/prosthesis’, 1 ‘misplaced nasogastric / orogastric tube’).
  • Medway NHS Foundation Trust reported a total of 2 Never Events (1 ‘wrong site surgery’, 1 ‘retained foreign object post-procedure’).
  • Queen Victoria Hospital NHS Foundation Trust reported a total of 2 Never Events (1 ‘wrong site surgery’, 1 ‘retained foreign object post-procedure’)
  • Surrey and Sussex Healthcare NHS Trust reported a total of 1 Never Event (‘wrong site surgery’)
  • Western Sussex Hospitals NHS Foundation Trust reported a total of 3 Never Events (2 ‘wrong site surgery’, 1 ‘wrong route administration of medication’).

Discussion:-

Although the NHS Trusts in the South East seem to be at / around the national average for the total number of ‘Never Events’ per Trust reported within this period, there appears to be a worryingly high number in the ‘wrong site surgery’ category.

Nationally, the percentage of ‘Never Events’ categorised as ‘wrong site surgery’ was 42% (178 of 424), but in the South East this rose to 48% (12 of 25) indicating that patients in the South East are more at risk of the most basis of errors from the doctors who are treating them.

The categorisation of these ‘Never Events’ (a to m) seem somewhat artificial and appear to me to exclude similar types of errors which would surely justify the ‘Never Event’ tag.

In particular:-

  • (d) ought to include, or there ought to be a separate category for, the provision of incorrect medication – it makes little sense to limit the ‘Never Event’ category to incorrect route administration of medication, as providing an incorrect medication can potentially be just as harmful and appears to fit the NHS’ definition of a ‘Never Event’.
  • similarly, (g) and (h) refer to the overdose of a restricted class of medications for limited reasons – but it is not clear why this category should not be extended to include any incident in which a patient suffers an overdose of any medication for any reason because, again, any such occurrence is potentially very harmful and appears to fit the NHS’ definition of a ‘Never Event’.

Alex is a Senior Medical Negligence Solicitor with many years experience dealing with a wide variety of claims.

If you or a loved one have suffered a ‘Never Event’ and need the assistance of an experienced and accredited team of Clinical Negligence Solicitors then please do not hesitate to phone us free on 0800 999 5585, request a call back or submit your case details.