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Never events

View profile for Judith Thomas-Whittingham
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In April 2009 the National Patient Safety Agency (NPSA) launched a ‘never events’ policy which applies to all NHS treatment in England. ‘Never events’ are events which are preventable and should never happen to patients in NHS case. There were eight events initially identified, including operating on the wrong part of the body, leaving a surgical instrument or swab inside a patient and the death of a woman following a haemorrhage after a pre-planned caesarean delivery.


Official figures last week revealed that there were 111 ‘never event’ blunders in 2009/2010. The NPSA confirm that the breaches occurred throughout the country, throughout the year and at different Trusts. There were 57 instances of ‘wrong site surgery’, which refers to an operation on the wrong limb or organ, or even on the wrong person. There were also 41 examples of misplaced feeding tubes which put patients at risk of bring fed directly into the respiratory tract.


The Department of Health has now added 14 other ‘events’ to the official list. The expanded list includes mistakes such as death or serious injury from a patient receiving the wrong blood or an incompatible organ, brain damage caused by untreated jaundice in newborns and deaths from an overdose of insulin administered in hospital.


Simon Burns, Health Minister, stresses that unsafe care cannot be tolerated: “Across the NHS there must be a culture of patient safety above all else. These measures will help to protect patients and give commissioners the powers to take action if unacceptable mistakes happen.”


NHS Medical Director, Professor Sir Bruce Keogh, agreed: "Never events by their very name should never occur in a modern NHS. The proposed list includes avoidable incidents with serious adverse consequences for patients.”


The identification of ‘never events’ shows that certain errors are simply inexcusable and Simon Burns has acknowledged that there is a commitment to extending the system of ‘never events’ further.


It is essential that lessons are learned and that the safety of patients is paramount. Hospitals have been warned that if they breach a ‘never event’ they are unlikely to receive payment for the treatment of that patient. It is my opinion that a breach of a ‘never event’ could also result in patients having a potential claim for clinical negligence.


If you believe you have been the victim of a ‘never event’, or if you have concerns that the treatment afforded to you has caused an injury, then we have a dedicated clinical negligence department who would be happy to advise you further.


By clinical negligence solicitor, Tom Mooney