The New NHS Never Events Policy and Framework

By John Tingle

In tort law we have a very well-known Latin phrase, ‘Res Ipsa Loquitur’ (the thing speaks for itself). An inference of negligence can be raised by the events that occurred. In the National Health Service (NHS) in England there is a similar concept,‘the Never Event’. The Never Event concept is a USA import into the NHS and was introduced  from April 2009. The list of what is to be regarded as a Never Event has been revised over the years in the NHS and is currently set out by NHS Improvement.

Never events include, 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 and so on. Never Events are defined in NHS policy documentation as:

“…patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.  Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event.” (p.6)

Never Events should not be happening to the extent that they are in England. The Secretary of State for Health and Social Care, Jeremy Hunt said last year that ’Never Events’, are not really falling in number – more than 1,000 in the last 4 years. After a consultation with stakeholders the Department of Health have produced a  new, Never Events policy and framework.One fundamental change has been the abandonment of the financial penalties that can be imposed on hospitals (Trusts) by commissioners of care if a Never Event results. Imposing fines could be viewed as reinforcing the perception of a blame culture. A more proactive approach is needed to avoid the ‘name and shame’ culture that encourages the punitive approach.

Recent  NHS Never Event Figures

Provisional publication of Never Events reported as occurring between 1 April and 30 November 2017.There were reported 139  Never Events in wrong site. In one case ovaries removed in error during a hysterectomy when plan was to conserve them.

  • 21 reports of wrong route administration of medication.
  • 46 reports of wrong implant/prosthesis.
  • 3 reports of wrong blood transfused.
  • 88 reports of retained foreign object post procedure, and these included:
    • Guide wire
    • Femoral line
    • Screw from instrumentation
    • Small piece of metal
    • Specimen retrieval bag.

A Shocking List of Errors

This is a shocking list of patient safety errors by any account. Reading all the above, the ovaries removed in error during a hysterectomy when plan was to conserve them is particularly devastating along with the wrong blood being transfused.

In total 332 Never Events are reported during this period. Numbers are subject to change as local investigations are completed.

Never Events are rare occurrences but the figures show that they are stubbornly prevalent and it will take some fresh patient safety policy making and thinking to reduce them. We accept we cannot have an error free health care environment as nobody is infallible but we can try to manage our patient safety system better and hopefully the revised NHS Never Events policy will produce reductions.

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

One thought to “The New NHS Never Events Policy and Framework”

  1. Dear Jonn
    Can we please discuss this? I have been Medical Director in UK in two Acute Trusts for over 15 years. In Wigan when I was Medical Directors, we reported 8 Never Events and we were crucified by the CQC and also DOH and the amount of money we spent investigating and educating was shocking and out of these 4 were not even Never Events but CCG classified them as Never Events and staff went through hell because of Never Events. Only one Never event resulted in some long-term harm to the patient but even that patient recovered. On the other hand, we had some other Events which are not Never Event and patient had serious harm. With good Governance we were able to reduce harm to patients by 90% and the Trust received 45 awards! Today 450 fewer patients die in the Trust and there is an excellent culture and good leadership and good governance. Hope to discuss this with you in person.

    In 2016, Mr Simon Stevens took me to meet her Majesty the Queen for my contribution to patient safety and good leadership and good governance.
    With kind regards

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