Figures show that NHS staff are carrying out one ‘never-event’ every day, despite the Government’s crackdown on these mistakes. These errors cost hospitals an estimated £800 million in compensation annually. Experts are calling for further action to address the unacceptable levels of never-events, attributing them to inadequate staffing levels and a lack of investment in the NHS. A MailOnline audit of a decade’s worth of NHS data reveals that there have been 4,328 never-events in England since 2013, equivalent to approximately eight per week.
The article includes two images. The first image depicts MailOnline’s audit of NHS data, highlighting the 4,328 never-events that have occurred in England since 2013. The second image displays the NHS trusts/private providers with the highest number of recorded never-events in the past decade.
Unfortunately, the article cannot be displayed properly as it contains an iframe that is not supported by the browser.The NHS has been plagued by shocking incidents, including cases where women had their reproductive organs removed instead of their appendix, men received unwanted circumcisions, and laser procedures were performed on the wrong eye. Other incidents involved patients having scalpels, surgical gloves, and even parts of a condom left inside them after surgery or medical procedures. In one unusual case, a prisoner managed to escape while undergoing treatment. These never-events have raised concerns about patient safety, prompting calls for improvement from officials. In 2014, then-Health Secretary Jeremy Hunt ordered hospitals to take significant measures to reduce the occurrence of these unacceptable incidents.
One tragic example of a never-event involved the death of a retired police officer, Max Dingle, whose head became trapped in his NHS hospital bed at the Royal Shrewsbury Hospital. The coroner ruled that his death was an avoidable accident and criticized the lack of resuscitation attempts despite the presence of a pulse and the patient’s request for life-saving intervention. The Shrewsbury and Telford Hospital NHS Trust, responsible for the hospital, was recently fined £1.3 million for failing to provide safe care to Mr. Dingle and another patient, Mohammed Ismael Zaman, who died under different circumstances.Retired police officer Max Dingle, 83, passed away 15 minutes after being discovered ‘entrapped’ on a ward at the Royal Shrewsbury Hospital on May 3, 2020. Senior coroner John Ellery stated that Mr. Dingle, from Newtown in Powys, mid Wales, was initially admitted to the hospital on April 27, 2020, due to ‘shortness of breath.’ His medical history revealed that he had a heart condition, lymphoedema, and sleep apnoea. On May 3, at 10 am, he was found with his head trapped between the rails and mattress of his hospital bed. He suffered a cardiac arrest and was pronounced dead at 10:15 am.
The article highlights the issue of ‘wrong site surgery’ in the NHS, which occurs once a week on average. The author argues that the true scale of the problem is being under-recorded by trusts. Patient charities and experts agree that the levels of never events are still too high. In 2022/23, wrong site surgery was recorded three times a week on average, triple the figure when the issue was first addressed by Mr. Hunt. The Royal College of Surgeons deems the level of never-events as ‘unacceptable’ and attributes it to NHS staffing levels, which increase the risk to patients. The spokesperson acknowledges the challenging circumstances in which surgeons work, including staff shortages, burn-out, and pressure to reduce waiting times. While there is a long-term workforce plan, immediate action is needed to fill vacancies and retain NHS staff.
Patient safety charity Action against Medical Accidents suggests that the NHS is failing to learn from never-events and warns that the problem may worsen in the future. The chief executive of the charity expresses frustration with the phrase ‘lessons will be learned’ and calls for investment and actionable change in the NHS. Rachel Power, chief executive of charity The Patients Association, emphasizes the human impact of never-events and rejects the notion that the NHS being busy is an excuse for such incidents. She asserts that preventative measures should be implemented to prevent these events from occurring.A total of 384 never-events occurred in the NHS in England during the 2022/23 year, according to a completed test. This data includes incidents from private providers who perform procedures on behalf of NHS services. These never-events range from surgeons operating on the wrong finger to unnecessary removal of an entire rib. Wrong site surgery accounted for the highest number of never-events, with a total of 1,806 cases recorded since 2013. Barts Health NHS Trust in London had the highest number of never-events, with 85 recorded since 2013. The top three also included Guy’s and St Thomas’ in London with 84 incidents and University Hospitals Birmingham with 83 incidents. Other NHS trusts in East Suffolk, Essex, Manchester, Leeds, and Liverpool also featured in the top 10. Ramsay Health Care UK, a private provider with 37 facilities across the country, was the only independent provider on the list with 58 incidents. It is unclear whether the incidents recorded in the private sector are solely taxpayer-funded procedures. It is important to note that a higher number of never-events recorded by an organization does not necessarily indicate it is more dangerous than others. Larger NHS trusts perform a higher volume of procedures, leading to a higher number of never-events. Reporting never-events can indicate a better safety culture as staff are more likely to admit such incidents rather than hiding them. However, this does not diminish the severity of the injuries suffered by some individuals. For example, in 2015/16, an unnamed woman had one of her fallopian tubes removed instead of her appendix due to her pregnancy and the distortion of her anatomy.Two men experienced severe injuries to their reproductive organs due to medical errors. In 2019/20, one man was supposed to undergo a frenuloplasty, a procedure to remove tight skin on the underside of the penis. However, a mix-up occurred during the surgery.
In 2001, Frank Hibbard underwent surgery to remove his prostate cancer. He was told that the operation would completely eliminate the cancer since it was contained within the prostate gland. Frank, a long-distance lorry driver, hoped that this would give him more years with his wife and children. Unfortunately, the surgery at the Luton & Dunstable University Hospital left a dangerous object inside him.
Surgeons accidentally left an 8cm-long piece of gauze in Frank’s pelvis during the operation. This mistake led to the development of angiosarcoma, a type of soft-tissue cancer. The medical team missed multiple opportunities to detect the cancer, causing Frank to suffer from years of pain. When the cancer was finally discovered in March 2014, it was too advanced to be treated. Frank passed away that same year at the age of 69. A coroner’s report confirmed that the gauze left inside his body had contributed to the development of the cancer.
The report stated that angiosarcoma can be caused by foreign objects, such as surgical sponges or gauze, left in the body for an extended period. Frank’s widow, Christine, was devastated when she learned the cause of her husband’s cancer. She described it as a part of her dying that day.
Overall, these cases highlight the devastating consequences of medical mistakes and the importance of ensuring patient safety during surgical procedures.A man who was scheduled for a cystoscopy woke up to find that he had been circumcised instead. This incident is just one example of the many harms suffered by patients in the UK. Other cases include having ovaries removed without consent, having the wrong testicle amputated, receiving unnecessary pacemakers, and getting cranial plates designed for another patient’s skull. Some patients even had contraceptive implants inserted without their request. In a recent case, a patient received a kidney transplant with the wrong blood type, resulting in rejection. Kidney donations are crucial for those on dialysis, who often wait for years for a suitable organ. Additionally, an audit revealed over 1,000 cases of objects being left inside patients, including scalpels, needles, forceps, gloves, and even a condom. Vaginal swabs were also commonly forgotten. Never-events are not limited to surgical incidents, as there have been cases of patients getting trapped between their bedrail and mattress, resulting in fatalities. One such case involved an 83-year-old retired police officer who died in the hospital. Other incidents include scalding patients with hot water and prisoners escaping during NHS care. The cost of compensating patients and families for never-events is estimated to be around £800 million annually. Each incident can cost an average of £1.9 million, depending on the circumstances. Factors such as the extent of harm, impact on the patient’s quality of life, ongoing healthcare needs, and psychological trauma are considered in determining compensation. The NHS acknowledges that never-events are rare but fully investigates each case.According to a spokesperson from the Department for Health and Social Care, never events are extremely rare, but when they do occur, NHS trusts are required to investigate and take steps to improve patient safety as part of the NHS Patient Safety Strategy.
A report from the Health Services Safety Investigations Body (HSIB) in 2019 highlighted the case of a woman known as Christine. After giving birth to her first child, Christine had a surgical tampon inserted, which should have been removed at the end of the procedure. However, the staff left the tampon inside her for five days. Surgical tampons are larger than normal ones and can have devastating consequences if left inside a patient.
Christine experienced extreme pain but was unaware of the cause. The HSIB report emphasized the importance of addressing never events and taking measures to prevent them in order to ensure the safety and well-being of all patients.Sandy Lewis, the director of a maternity investigation programme, emphasized the physical and psychological effects of medical incidents, stating that they can cause pain, bleeding, infection, and have a negative impact on a patient’s mental well-being. Lewis specifically mentioned a case involving a woman named Christine who had to seek private counseling and felt that the incident affected her ability to bond with her baby.
Barts Health NHS Trust, King’s College Hospital NHS Foundation Trust, University Hospitals Birmingham NHS Foundation Trust, and Ramsay Health Care UK all expressed their commitment to patient safety and the importance of reporting incidents. They emphasized the need to learn from mistakes and improve the quality of care provided. These organizations conduct thorough investigations into never-events and involve patients and their families in the process to prevent recurrence.
The article also mentioned that the NHS has been recording never-events for over a decade but has changed how the data is measured. Prior to 2014/15, only incidents where a patient was directly harmed were included, but this was expanded to include incidents with the potential to harm a patient. This change resulted in a significant increase in the number of never-events recorded in subsequent years. In 2017/18, the NHS made a minor change in the sub-categories used to classify never-events.
