"Never Event" is a term used to describe certain serious patient safety incidents which can occur in hospital. What sets Never Events apart from other types of serious incidents is that they are regarded as being wholly preventable when appropriate safety protocols are followed by healthcare professionals. Although they make up a small proportion of all reported safety incidents in the NHS, Never Events happen hundreds of times per year in hospitals across the country.
In December 2018, the Care Quality Commission published a report on Never Events entitled "NHS Safety Culture and the Need for Transformation". The Regulator looked at data from a sample of NHS trusts and concluded that despite the hard work of frontline staff, patient safety could be improved.
What incidents are classed as Never Events?
There are currently 15 types of Never Event that fit the NHS definition. The most recent list published in January 2018 features incidents such as wrong-site surgery; wrong implant/prosthesis; misplacement of nasogastric or orogastric tubes; chest or neck entrapment in hospital bed rails; and retention of foreign objects post-surgery. The full 2018 list of Never Events can be found on the website.
Never Events have the potential to cause serious harm to patients. For example, in the case of a foreign object left in the body during surgery, the patient may go on to experience post-operative pain and infection, which could lead to sepsis. In some circumstances, this could be life-threatening. Once a retained foreign object has been detected, a further surgical procedure may be required to remove it. Not only does this mean extra time in the operating theatre, it will often mean an extended stay in hospital for the patient, who may need to take further time off work to accommodate a longer recovery period. It can undermine their confidence in the healthcare system and cause distress to the patient and their family.
As well as Never Events having a direct impact on patients, it is easy to see how they can affect the staff involved in the treatment in question. Further still, Never Events clearly have a financial implication for NHS trusts in terms of the cost of additional treatment and litigation costs where clinical negligence claims are brought in respect of substandard treatment resulting in harm.
What happens when a Never Event occurs?
When a Never Event happens, which has caused or could cause serious harm to a patient, it must be reported and the patient must be informed. According to the NHS Constitution, an apology should be given and arrangements should be made for any reasonable support that the patient needs. By reporting Never Events and sharing insights at a systemic level, the NHS aims to learn from practice and work towards preventing such incidents from happening again in the future. This is vitally important in relation to Never Events, which by their nature are preventable.
In reality, not all Never Events result in harm. According to data published by NHS Improvement and the National Reporting and Learning System, around 74% of the two million patient safety incidents reported annually by NHS trusts caused no harm to the patient. Only when a patient has suffered harm as a result of a Never Event will there be a potential clinical negligence claim to be brought. Injury is one of the criteria for succeeding in a civil claim for compensation arising out of clinical negligence.
Our clinical negligence team has experience in representing NHS patients who have suffered harm as a result of Never Events at inquests and in claims arising out of wrong site surgery and misplacement of nasogastric tubes.
If someone has been injured as a result of a Never Event, they may be entitled to compensation for their pain, suffering and certain financial losses arising out of the incident.