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'Never Events' Cause Never Ending Distress

View profile for Malcolm Underhill
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A patient’s entire testicle removed instead of the cyst on it.  The removal of a woman’s fallopian tube instead of an appendix.  A scalpel blade being left inside a patient following an operation.

The above is not a synopsis of the latest Hollywood horror movie but instead examples of real life ‘never events’ which occurred in NHS hospitals over the past four years.       

Nearly 1,200 incidents of “never events” have occurred in British hospitals in the last four years.  Even Health Secretary Jeremy Hunt, who in a recent poll had the honour of being named the most disliked frontline politician, takes never events so seriously that he famously keeps a whiteboard updated with the latest disasters on a wall in his ministerial office. 

Doctors Equipment

What is a “Never Event”?

Never events is an apt term because they are defined as “serious incidents that are wholly preventable, as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.”  In other words, they should never occur as they are absolutely avoidable.

“Never events” cover a range of medical incidents such as:

  • wrong site surgery
  • retained foreign objects following operations
  • providing wrong implants/prosthetic body parts to patients
  • wrong route administration of chemotherapy

Never events do not have to include unacceptable incidences occurring during treatment or surgical procedures.  In the year 2014/15, the list of published never events included two cases of transferring prisoners escaping and four cases of patients being misidentified.

Why do “Never Events” Occur?

The simple answer to this is because human beings are involved.  Over the last few decades, researchers have identified that things such as system breakdowns, technical errors, communication failures, and most commonly a combination of all these contribute to why never events occur.  Similar to plane crashes, even though causes are identified and measures are put in place to prevent that specific type of accident happening again, hypodermic needles still sometimes get left behind after a patient has been sewn up in theatre.

In an article published in Surgery, a group of doctors set out to discover why never event continued to occur despite all the research and the subsequent implementation of operating theatre checklists, briefings, barcode systems, and safety counts.  They employed an investigation model initially developed to study aviation disasters, and it turned out there was not one person (this sounds unclear. Please re-word), machine, or system to blame when never events occurred.

In most cases, unsafe actions played a part in the error and usually involved things like a confirmation bias. (“There can’t be a sponge left behind because I checked.”).

The team then examined the preconditions that led up to the errors occurring and found overconfidence and miscommunication often played a part.  They suggested that by engaging other team members (or even computer systems) the workload of the doctor or surgeon could be decreased and that preventing preconditions from occurring is the real key to avoiding errors and improving patient safety.

The Impact on Patients

Katherine Murphy, chief executive of the Patients Association, has said: “It is a disgrace that such supposed ‘never’ incidents are still so prevalent. With all the systems and procedures that are in place within the NHS, how are such basic, avoidable mistakes still happening? There is clearly a lack of learning in the NHS.

“These patients have been very badly let down by utter carelessness. It is especially unforgivable to operate on the wrong organ, and many such mistakes can never be rectified.”

And here we get to the heart of the issue.  “Never events” are named as such because they should never happen and when they do they can change a person’s life forever.  One cannot help but think of Maisha Najeeb, who was a victim of a mix-up in the operating room at London’s Great Ormond Street Hospital.  Maisha was a healthy 10-year-old girl, despite having a rare medical condition that involved her arteries and veins getting tangled.

She had successfully received embolisation treatment - which involves injecting glue to block off bleeding blood vessels and an injection of a harmless dye to check the flow of blood around the brain - during hospital visits.

But in June 2010, the two syringes were mixed up, and glue was wrongly injected into the artery to Maisha's brain, causing permanent brain damage.  Although the event is not classified as a never event, it highlights how one simple error during treatment or surgery can ruin a life completely.

Maisha’s family brought a successful claim for compensation against the NHS and the total payout over the little girl’s lifetime is estimated to total £24 million.

The family’s solicitor was quoted as saying, “What is so heart-breaking about this case is that the injury was so avoidable.”

We can only hope that there will be a time when “never events” will truly never occur.

At IBB, our personal injury team, led by Malcolm Underhill, has the expertise and knowledge to advise and represent you if you wish to make a claim for clinical negligence. To talk about how we might be able to help, please phone us on 0333 123 9099, email us at  or fill in our contact form.  Any discussions you have with us will be in the strictest of confidence.

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