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29 April 2019 | Comment | Article by Lynda Reynolds

NHS “Never Events”: What are they and why do they happen?

NHS Never events recently made it in to the news again after a man due for a cystoscopy (a procedure to look inside the bladder with a thin camera) was circumcised after his notes were mixed up with those of another patient.

Never events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.

Each year a report is published by NHS Improvement detailing the type and number of incidents reported and the number of never events reported by each trust.

Between 1 April 2018 and 31 January 2019, 423 incidents which meet the definition of never events were reported. This number may, however, be subject to change as investigations are completed.

Never events include incidents such as wrong site surgery, use of the wrong implant/prosthesis, retained foreign objects and misplaced naso or orogastric tubes.

The most commonly reported events in this reporting year included:

  • Injections to the wrong eye;
  • The wrong tooth being removed;
  • Retained vaginal and surgical swabs;
  • Wrong skin lesion being removed; and
  • Wrong hip prosthesis or implant.

Some of the NHS Trusts who reported the most never events included Walsall Healthcare NHS Trust, Barts Health NHS Trust, King’s College Hospital NHS Foundation Trust, Royal Free London NHS Foundation Trust and University Hospitals Birmingham NHS Foundation Trust.

When a never event occurs the Trust is expected to conduct its own investigation with a view to identifying the cause and to learn from its mistakes, however never events have the potential to cause serious harm to a patient or cause them to undergo a further unnecessary procedure to rectify the mistake.

Ultimately by their definition, these are events which are preventable. If you have been a victim of a never event or any other medical error which you believe could have been avoided, you may be entitled to compensation.

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Author bio

Lynda Reynolds


Lynda is a Partner and Head of the Inquest Team that forms part of the Clinical Negligence Department in the London office. She has considerable experience in assisting families with inquests that relate to deaths in hospital or care homes, where medical negligence is suspected.

She has been instructed on Article 2 inquests, inquests with juries and complicated medical inquests where numerous experts have been instructed. Where necessary she will make submissions on the Coroner’s power to issue Prevention of Future Deaths reports. Her inquest role combined with subsequent civil claims ensures that she is a specialist on Fatal Accident Act Claims. She is recognised in both UK Chambers & Partners and Legal 500.

In addition to her role in the Inquest team Lynda has a caseload of complex clinical negligence matters which include cerebral palsy, brain injuries, spinal injuries and cauda equina claims.

Disclaimer: The information on the Hugh James website is for general information only and reflects the position at the date of publication. It does not constitute legal advice and should not be treated as such. If you would like to ensure the commentary reflects current legislation, case law or best practice, please contact the blog author.


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