NHS England defines ‘Never Events’ as “serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers”.
The Never Events List, last updated in February 2021, includes the following:
- Wrong site surgery
- Wrong implant/prosthesis
- Retained foreign object post procedure
- Mis-selection of a strong potassium solution
- Administration of medication by the wrong route
- Overdose of insulin due to abbreviations or incorrect device
- Overdose of methotrexate for non-cancer treatment
- Mis-selection of high strength midazolam during conscious sedation
- Failure to install functional collapsible shower or curtain rails
- Falls from poorly restricted windows
- Chest or neck entrapment in bed rails
- Transfusion or transplantation of ABO-incompatible blood components or organs
- Misplaced naso- or oro-gastric tubes
- Scalding of patients
- Unintentional connection of a patient requiring oxygen to an air flowmeter
Never Events require investigation under the Serious Incident framework. By fully analysing each occurrence of a Never Event, the aim is to understand how and why it occurred and then to take action to reduce the risk of recurrence. This process should include full and meaningful engagement with the patient, families and carers at the beginning of and throughout any investigation.
In its provisional report, the NHS has confirmed that 325 Never Events were reported across the country between 01 April 2020 and 28 February 2021. Of these the most common Never Events were wrong site surgery (131 cases), retained foreign objects post procedure (70 cases), misplaced naso or oro gastric tubes and feed administered (29), wrong implant/prosthesis (26), unintentional connection of a patient requiring oxygen to an air flowmeter (26) and administration of medication by the wrong route (18).
Whilst this is lower than the 472 Never Events that were reported between 01 April 2019 and 31 March 2020, it is likely that the lower number of operations performed during the Covid-19 pandemic accounts for much of this difference, particularly considering that 496 Never Events were reported between 01 April 2018 and 31 March 2019.
Never Events cannot usually be defended and victims should seek advice from a specialist medical negligence solicitor in order to make a claim for compensation for the avoidable harm that they have suffered.
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