Importance Score: 85 / 100 🟢
NHS ‘Never Events’ Data Reveals Multiple Instances of Wrong-Site Surgery and Medical Errors
Official data has revealed alarming figures concerning patient safety within the National Health Service (NHS), indicating that medical professionals are performing surgery on the incorrect body part on average three times per week. These critical incidents, officially termed ‘never-events’ by the health service – signifying mistakes of such severity they should be entirely preventable – totaled 334 occurrences between April 2024 and January of this year. The report highlights serious lapses in protocol, including accidental organ removal and surgical instruments being left inside patients.
Catastrophic Medical Blunders: Types of ‘Never Events’
These ‘never-events’ encompass a range of serious errors, extending beyond surgical mishaps. Examples include:
- Surgery performed on the wrong body part.
- Operating on the incorrect patient.
- Accidental removal of organs.
- Foreign objects, such as scalpels, left inside patients post-surgery.
- Patient falls from insecure windows.
- Escapes of prisoners undergoing hospital treatment.
Financial Ramifications of Medical Negligence
The financial burden of these ‘never-events’ is substantial. Compensation payouts for patients who are harmed or permanently disabled due to such errors are estimated to cost the NHS approximately £800 million annually. This considerable sum underscores the urgent need for improved patient safety measures and error prevention within NHS trusts.
NHS Trusts with the Highest Reported Incidents
The data reveals significant variations in the number of reported ‘never-events’ across different NHS Trusts. Some trusts have unfortunately recorded a disproportionately high number of these serious incidents.
Trusts with Elevated ‘Never Event’ Figures:
- University Hospital Southampton NHS Foundation Trust: Reported the highest number in England with 11 incidents.
- Royal Free London NHS Foundation Trust: Followed with 9 reported never-events.
- University Hospitals Birmingham NHS Foundation Trust & University Hospitals of Derby and Burton NHS Foundation Trust: Joint third, each reporting 8 never-events.
Breakdown of ‘Never Events’ by Incident Type
Analyzing the types of ‘never-events’, ‘wrong site surgery’ emerged as the most frequent error. This category includes procedures conducted on the incorrect body location, and in some instances, on the wrong patient altogether.
Prevalence of Wrong Site Surgery:
- Total Wrong Site Surgeries: 151 incidents.
- Wrong Patient Operations: 9 cases.
- Wrong Side of Body Operations: 32 instances.
Accidental Organ Removal and Retained Surgical Items
Disturbingly, the report also documented two instances of patients undergoing organ removal without medical necessity. While specific details remain undisclosed in the NHS report, past cases have involved serious errors such as unintended circumcisions and the removal of reproductive organs instead of the appendix.
Leaving surgical items inside patients post-operation was the second most common ‘never-event’, with 92 such cases recorded.
- Retained Items Cases: 92 incidents.
- Disposable Items Left Behind (e.g., gloves): 7 cases.
- Surgical Tools Retained (e.g., scalpels, drill bits): 16 cases.
- Most Common Retained Item: Vaginal swabs.
Incorrect Implants and Prosthetics
Incidents involving patients receiving the wrong type of implant or prosthetic constituted another significant category of ‘never-events’, accounting for 41 reported cases. Examples from the NHS report include instances of incorrect hip implants and a case where a patient received an incorrect prosthetic thumb.
Patient Impact and Calls for Improved Safety
The NHS report does not detail specific patient outcomes related to these ‘never-events’. However, patient advocacy groups have consistently emphasized the profound and lasting impact these errors have on victims’ lives.
Rachel Power, chief executive of The Patients Association, has previously stated that patients can suffer enduring physical and psychological consequences as a result of these errors, highlighting that such incidents should never occur within the NHS.
Calls for Action and Historical Context
Health officials have repeatedly voiced concerns about the persistent occurrence of ‘never-events’ within the NHS, urging hospital administrators to prioritize and enhance patient safety protocols.
In 2014, the then-Health Secretary Jeremy Hunt mandated that hospitals significantly improve their safety records to reduce these ‘unacceptable’ never-events. At that time, he noted the concerning frequency of wrong-body-part surgeries occurring weekly and suggested potential underreporting of the issue by trusts.
Factors Contributing to Persistent ‘Never Events’
Organizations representing medical professionals have attributed the consistently high number of ‘never-events’ over the last decade, in part, to NHS staffing shortages and the increased pressures these shortages place on medical teams.
It is important to note that a higher number of reported ‘never-events’ in a particular NHS trust does not automatically indicate a more dangerous environment. Larger trusts, performing a greater volume of procedures, are statistically more likely to experience a higher number of such incidents. Furthermore, proactive reporting of ‘never-events’ may reflect a more transparent and robust internal safety culture within a trust, indicating a willingness to acknowledge and learn from mistakes.
Trust Responses and Ongoing Investigations
All NHS trusts named in the report were contacted for comment regarding their ‘never-event’ data.
A spokesperson for University Hospitals of Derby and Burton emphasized that patient safety remains their ‘top priority’. They stated that while ‘never-events’ are rare, particularly given the high volume of operations and procedures they undertake annually (approximately 50,000 operations and over 100,000 outpatient procedures), they should not happen, and they sincerely apologized to affected patients. The spokesperson added that the trust takes these events seriously, conducting thorough investigations in each case to learn from what occurred and implement immediate measures to enhance process safety.
The latest NHS report on ‘never-events’ is provisional, suggesting that further events may be added or reassessed in subsequent updates.