Never events in the NHS 2022/23 – Latest figures released

What are Never Events?

The NHS defines Never Events as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.”

The NHS suggests that if a trust is experiencing a higher number of these, or is seeing certain incidents being repeated, then it could be a sign of an area of weakness within that specific trust.

The NHS themselves say that even a single Never Event within an organisation could be an indicator of poor practice.

Never Events will be of grave concern to patients, as they can lead to severe injury, or in some cases even death.

What different types of Never Events are there?

NHS England records the Never Events under a number of categories. For 2022/23, the Never Events recorded fell into the following categories.

• Wrong site surgery
• Retained foreign object post procedure
• Wrong implant/prosthesis
• Misplaced naso or oro gastro tubes and feed administered
• Administration of medicine by the wrong route
• Unintentional connection of a patient requiring oxygen to an air flowmeter
• Overdose of insulin due to abbreviations or incorrect device
• Transfusion or transplantation of ABO-incompatible blood components or organs
• Falls from poorly restricted windows
• Chest or neck entrapment in bed rails
• Overdose of methotrexate for non-cancer treatment
• Misselection of a strong potassium solution
• Failure to install a functional collapsible shower or curtain rails
• Mis-selection of high-strength midazolam during conscious
• Scalding of patients

Do Never Events require investigation?

As mentioned above, Never Events are an indication that there is a serious problem at a hospital with healthcare practice.

All trusts are encouraged to report any Never Event that occurs and are expected to conduct a local investigation into the incident. This is so that any mistakes can be learned from, and any underlying issues with patient care at the trust can be identified.

How many Never Events were there in 2022/23?

The latest provisional data released earlier his month shows a total of 384 Never Events, shared across 206 NHS hospitals and other healthcare providers.

The initial results show that there has been a slight decrease in the number of Never events since last year. In 2021/22, there were 407 recorded Never Events.

What Never Events occurred in 2022/23?

As part of the provisional data release, NHS England detailed specific Never Events that occurred across England.

Blackwater Law have looked through the data to find some of the most concerning.

There were two recorded incidents of patients having ovaries removed when the plan was for them to be conserved. In one case, both ovaries were removed when the surgical plan was to remove just one.

In one incident, a patient received a skin biopsy intended for another patient. On three occasions patients fell from windows, due to a window restrictor failing.

On five occasions, patients received the wrong blood during a blood transfusion. This is particularly concerning as if you receive the blood of the wrong type, your immune system could attack the red blood cells. This can be life-threatening.

Across all trusts, there were 96 occasions of a foreign object being left after a procedure. This included guide wires, part of a drill bit, surgical forceps and 16 incidents of surgical swabs being left in a patient after an operation

What Never Event was the most common?

The most common Never Event that was recorded in 2022/23 is what is known as a ‘wrong site block.’ This is where the wrong site is blocked from pain relief using local anaesthetic.

Which NHS trusts had the most Never Events in 2022/23?

As part of the provisional data release, NHS England provides the number of Never Events that occurred at named trusts.

The trusts that recorded the most Never Events between March 2022 and April 2023 were University Hospitals Birmingham NHS Foundation Trust, and Manchester University NHS Foundation Trust both with ten recorded Never events.

Behind those Royal Free London NHS Foundation Trust and University Hospitals of Leicester NHS Trust each reported eight Never events.

South Tees Hospitals NHS Foundation Trust and Barking, Havering and Redbridge University Hospitals NHS Trust followed each with seven Never Events.

The Ten NHS Trusts with the most recorded Never Events are as follows:

1. University Hospitals Birmingham NHS Foundation Trust – 10
2. Manchester University NHS Foundation Trust – 10
3. Royal Free London NHS Foundation Trust – 8
4. University Hospitals of Leicester NHS Trust – 8
5. South Tees Hospitals NHS Foundation Trust – 7
6. Barking, Havering, and Redbridge University Hospitals NHS Trust – 7
7. Birmingham Women’s and Children’s NHS Foundation Trust – 6
8. East Kent Hospitals University NHS Foundation Trust – 6
9. Hull University Teaching Hospitals NHS Trust – 6
10. Royal Devon University Healthcare NHS Foundation Trust – 6

The impact of Never Events

As discussed, Never Events can have devastating impacts when it comes to patient safety. Never Events can lead to serious, permanent injury as well as death.

Commenting on the latest figures, Jason Brady, Partner & Head of Blackwater Law said: “It is concerning to see the details of these ‘Never Events.’ At Blackwater Law we see the impact that these incidents have, not just on the person affected, but also on their families.

These incidents are especially concerning for patients and their families as they are avoidable incidents”

If you suspect that you or a loved one has suffered because of a Never Event, you could be entitled to claim compensation for your injuries.

For free initial advice on your claim, contact one of our expert team today, who can help you start your claim.