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Negligent Hospital Treatment: Never Events


    Never Events are those nursing, medication and surgical errors that the Department of Health recognise should never occur in an efficiently run hospital. Can they be avoided?

    By Kerstin Kubiak

A recent investigation by the BBC revealed that more than 750 patients had suffered from these “never” events as a result of negligent hospital treatment between 2009 and 2012, which is an alarmingly high number. The BBC also reported that the NHS state the risk of a never event occurring is 1 in 20,000. Surely if an event should never happen then even a seemingly small risk is too high?

The ‘Never Events’ list includes:

  • wrong site surgery
  • wrong implant/prosthesis
  • retained foreign object post-operation
  • wrongly prepared high-risk injectable medication
  • intravenous administration of epidural medication
  • misplaced nasogastric or orogastric tubes
  • misidentification of patients
  • maternal death due to post partum haemorrhage after elective Caesarean section.

How can the risk of these events be reduced?

The World Health Organisation (WHO) Surgical Checklist would help to eliminate a lot of these errors but it seems that some hospitals still fail to use this checklist and therefore these events continue to occur.

The WHO surgical safety checklist sets out three stages of an operation: Before the induction of anaesthesia (“sign in”), before cutting the skin (“time out”) and before the patient leaves the operating theatre (“sign out”). At each point, a checklist coordinator must confirm that the surgery team has completed the listed tasks before it proceeds with the operation. Tasks within the checklist to be completed before surgery include confirming the patient’s identity and confirming the details of the procedure planned, and then after the surgery include ensuring all surgical equipment is accounted.

On the face of it, it should be completely impossible to leave a surgical instrument or swab inside a patient, and indeed many of the “never” events would be avoided if the checklist was followed consistently and conscientiously, however there is no evidence that it is being followed as these events continue to occur. The recent study shows that retained surgical equipment was the most commonly occurring “never” event.

Many surgeons say that they would insist the checklist was used if they or their family were due to undergo surgery. If this is the case why should patients be expected to bear a risk that a well-informed surgeon would avoid for him or herself.

There also appears to be no adequate system for reporting these events, which means that learning opportunities must be frequently missed within the NHS.

Effects of suffering a Never Event

The effects of “never” events can be catastrophic for the patient which should heighten the burden on medical professionals to ensure these events never happen. The BBC investigation highlighted 2 cases: one where the patient had a pair of forceps left inside her body following surgery causing her constant abdominal pain and the other where a lady sadly died after a feeding tube was wrongly inserted into her lung.

As clinical negligence lawyers we are often approached by clients who have suffered injury where it becomes clear after investigation that the injuries were caused by the most basic omissions in care. A member of the Clinical Negligence team previously acted for the family of a lady who was given 4 times the maximum dose of a chemotherapy drug due to a prescription error, which sadly caused her death.

If you or a member of your family are injured in this way, then you should seek advice from a specialist clinical negligence solicitor to ensure that the event is recognised and you are compensated for your avoidable injuries.

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