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Posted on 24th April 2017

Never events, what you should know

NHS England have encouraged an honest and open approach to reporting. They ask staff to report all never event incidents on the Strategic Executive Information System (StEIS). The figures below are from the report compiled by NHS England for the period of 1 April 2015 and 31 March 2016. The report was published in January 2017.

What are never events?

Called never events because they are things that should never have happened. These are mostly preventable events that should act as a "red flag" that the organisation’s patient safety is not as robust as it should be.

Definition of a never event

In April 2015, the definition of a never event changed from causing serious harm or death, to the potential to cause serious harm or death. Because of this, and the NHS becoming more honest in their reporting, the figures for 2015/16 are higher than previous years.

How many never events were there in 2015/16

In total, with the new definitions, there were 447 incidents classed as never event in hospitals. October 2015 and March 2016 saw the most across all the trusts with 50 reported in each month.

Examples of NHS never events

During this period, there were 179 incidents of wrong site surgery. This is when the wrong part of the body has a procedure performed on it. The highest number of incidents were for "wrong site block" which accounted for 42 incidents, "Wrong tooth/teeth removed", which accounted for 33 incidents, "wrong skin lesion removed" which happened 19 times and "wrong eye" accounting for 12 of the 179 incidents.


It wasn't just during surgery that it went wrong. There were 25 cases of medication being given incorrectly including an epidural being given intravenously, 59 cases of the wrong implant or prosthesis being used, and 107 people had foreign objects left inside them after a procedure.

Which hospital trust had the highest reported number of incidents?

According to the figures published by the NHS, Guy's and St Thomas' NHS Foundation Trust had the most hospital never events in England, accounting for 15 of the 447 incidents. Of these 15, 6 incidents related to "wrong site surgery". 

They were closely followed by Bart’s Health NHS Trust who reported 14 never events during the same period.  

What has been said about never events in the past?

In July 2016, The Press Associate (PA) carried out an investigation that revealed that 1,100 people between 2012 and 2106 had been the victim of a never event. This included more than 400 people who had wrong site surgery.

The PA found that another common “never event” is when objects such as needles, scalpel blades, drill guides and swabs are left inside a patient following their surgery. This happened to 420 people during those four years.

The investigation revealed the following serious mistakes:

  • A woman had her fallopian tubes removed instead of her appendix
  • During a blood transfusion, diabetic patients were not given insulin or were given the wrong blood type
  • Feeding tubes meant for the stomach were inserted into a patient’s lung – this could be fatal
  • Wrong site operations on hips, legs and knees
  • One woman had her kidney removed instead of her ovary
  • At the time an NHS England spokeswoman said: "One never event is too many and we mustn't underestimate the effect on the patients concerned. However, there are 4.6 million hospital admissions that lead to surgical care each year and, despite stringent measures put in place, on rare occasions these incidents do occur.”

NHS England have released data that shows there were 338 “never events” from April 2013 to March 2014, 306 from April 2014 to March 2015 and 254 events from April 2015 to December 2015.

Because of the changes in the definition of a never event it is hard to compare the latest figures to those previously released.

Can you claim for a never event?

If the never event caused you harm then you can claim. Here at Negligence Claimline our friendly team are here to help you get the support you need. Working with a panel of specialist medical negligence solicitors, we can assist you with your potential claim.

Sometimes an apology is enough, but in other cases compensation will be the only solution to help you get your life back on track.

Our service, putting you in contact with one of our expert panel members, is free and you are not obliged to take the advice the solicitor gives you, or to progress your claim any further if you do not wish.


Further Information