NHS Should 'Do Better' As Figures Show Scale of Never Events

Peter Russell

September 17, 2019

Mistakes by the NHS led to hundreds of patients experiencing problems with their care so serious that they should never have happened, new data showed.

The figures were released to coincide with the first World Patient Safety Day organised by the World Health Organisation (WHO).

Matt Hancock, Secretary of State for Health and Social Care, said: "The NHS is one of the safest healthcare systems in the world, but of course we can do better."

Information obtained by the PA news agency found there were 621 'never events' in NHS hospitals between April 2018 and July this year.

The provisional data showed a number of cases where doctors operated on the wrong body parts, and left surgical tools, gloves, chest drains, and drill bits inside patients.

Cases included:

  • Amputation of a wrong toe

  • A patient who had the wrong part of their colon removed

  • Two men who were mistakenly circumcised

  • Some patients given overdoses of drugs, including insulin

  • A woman who had a lump removed from the wrong breast

  • Two cases where a biopsy was taken from the cervix rather than the colon

  • Six women who had ovaries removed in error during hysterectomies

Regional Differences

The figures showed that some NHS trusts had higher error rates than others. Barts Health NHS Trust in London had the most errors, with 17 never events in the 16 month period, including eight cases of wrong site surgery.

Walsall Healthcare NHS Trust had the next highest with 13, followed by Guy's and St Thomas' NHS Foundation Trust and University College London Hospitals NHS Foundation Trust, which had 12 each.

The NHS said the figures should be seen in the context of the 535,248,185 patient interactions in 2018 to 2019. A spokesperson for NHS England said: "While incidents like these are thankfully extremely rare, it is vital that when they do happen hospitals investigate, learn and act to minimise risks.

"The patient safety strategy published in July gives NHS staff even more support to do their job and includes a new education programme and a world leading incident reporting system to reduce the risks of human error."

World Patient Safety Day

Professor Derek Alderson, president of the Royal College of Surgeons, commented: "While these cases are very rare, never should mean never. Never events are exceptionally traumatic for patients and their families.  They can also be devastating for the surgeons and healthcare staff involved. 
"NHS staff are there to care for patients, so knowing you have caused harm is incredibly distressing. 
"It is vital that all theatre staff use, and are involved in, the WHO pre- and post-operative checklist process, as these have been designed to help prevent serious incidents.

"It is also important that the NHS continues to promote a culture of openness and transparency, both in terms of publishing surgeons' outcomes and the number of never events that, sadly, occur. This will allow surgical teams to admit mistakes and learn from them, so that hopefully they do not happen again."

The WHO said that worldwide there were 134 million adverse events each year due to unsafe care in hospitals in low- and middle-income countries, leading to 2.6 million deaths annually.

It said 4 out of 10 patients were harmed in primary and ambulatory settings.


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