Surgical ‘Never Events’ in the NHS

NHS Improvement has just published a report on Surgical ‘Never Events’.The report presents an analysis of the local investigation reports into 38 surgical, ‘Never Events’ from across England that occurred between April 2016 and March 2017 (the last full year with data available).

There were 20 cases of wrong site surgery; four of the wrong implant being inserted; and 14 of retained foreign objects. The wrong site surgery section of the report contains an alarming catalogue of errors and they include the following reported cases. In ophthalmology a patient had unnecessary laser eye surgery.Another patient during surgery to correct an eye condition had the wrong procedure performed. In anaesthetics a nerve block was administered on the wrong side of a patient.Another patient had a pain-relieving injection given into the wrong hip joint .

In dermatology a patient had the wrong naevus removed.In endoscopy a scope was inserted by mistake into the cervix of a patient.In orthopaedics during surgery for a hand injury, the wrong finger was operated on.A surgeon in another case made an incision at the wrong site when due to  perform surgery for a trigger thumb.Other ‘Never Events’ are also reported.

These errors speak for themselves in terms of gravity and are unforgivable by any account.The report goes into some detail about these errors and one contributing factor identified was safety culture:

“In three cases the nursing staff did not feel able to speak up about their concerns. Two involved new or junior nursing staff and one related to experienced theatre staff not feeling able to speak up during a procedure that they were unfamiliar with. In two cases safety processes were described as not being embedded in routine practice.(p18)

The report states that the time available for safety checks was raised as an issue in six cases where these checks were either not done or not done properly.Failures in communication were also a contributing factor.In three cases staff were busy with other tasks which lead to communication failures.

Written Communication

The report states that written communication was a contributory factor in eight cases. In one case the documentation was described as “poor throughout”. In several cases the theatre (operating) list was wrong. There were discrepancies in notes in some other cases:


A failure to follow hospital policies for safe site surgery was found as a contributing factor for errors taking place in many cases. In one hospital staff had developed unsafe workarounds as they felt the safety processes, checks were too time consuming. In two cases no safety checklists were used routinely. Poor communication with the patient when confirming and/or marking the site for surgery was a factor in four cases.

The report discusses hospital responses and actions to the, ‘Never Events’ and draws out learning themes, challenges, to avoid these problems recurring and these include:

-Sharing solutions-there is a need to share more effectively problems and solutions when problems arise.

Safety culture and speaking up-the need to create a receptive team climate that is not intimidating to staff and conducive to facilitative patient safety learning is stated. Reflective safety checks, handovers are needed and not done just by rote, unthinkingly. A good staff situational awareness needs to be fostered and interruptions and distractions need to be guarded against by staff.

Overall an excellent report which contains sadly some very disturbing surgical errors.The report identifies key themes and challenges along with advocating some excellent patient safety strategies.

John Tingle

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.

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