Never events in the NHS 2023/24 – 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 2023/24, the Never Events recorded fell into the following categories.

• Wrong site surgery
• Retained foreign object post-procedure
• Wrong implant/prosthesis
• Misplaced naso or oro gastric tubes
• Administration of medication by the wrong route
• Transfusion or transplantation of ABO-incompatible blood components or
  organs
• Overdose of insulin due to abbreviations or incorrect device
• Unintentional connection of a patient requiring oxygen to an air flowmeter
• Overdose of methotrexate for non-cancer treatment
• Mis-selection of a strong potassium solution
• Scalding of patients
• Falls from poorly restricted windows
• Failure to install functional collapsible shower or curtain rails

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 2023/24?

The latest provisional data released earlier his month shows a total of  370 Never Events, shared across 136 NHS hospital trusts and other healthcare providers from April 2023 to March 2024.

The number of Never Events has been gradually decreasing over the last couple of years, in 2022/23 there were 384 Never Events, and the year before that there were 407 Never Events recorded across the NHS.

What Never Events occurred in 2023/24?

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

Blackwater Law has reviewed the data to highlight some of the most concerning.

Across the NHS, there were 81 incidents where a foreign object was left inside a person after their procedure. These range from swabs, needles and parts of surgical equipment. Incidents like this lead to needed, further surgery for the patient as well as a higher risk of infection.

There were 6 separate occasions where a patient received a procedure that was meant for someone else, and 3 incidents where a patient had an organ or structure removed when it should have been preserved.

There were 9 cases of patients receiving the wrong blood type for a blood transfusion, which could lead to the patient needing further blood transfusions.

One patient was scalded by a bowl of boiling water from a kettle that was left beside their bed, and one person fell from a window that was not properly secured.

What Never Event was the most common?

In 2023/24, the most common Never Event across the NHS were patients having the wrong skin lesion removed or tested by biopsy. This Never Event happened 52 times. Lesions often need to be removed if they are suspected to be cancerous, removing the wrong one could lead a patient to be exposed to a potentially cancerous lesion for longer than necessary.

The Never Event that was most common 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 2023/24?

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

The trust that recorded the most Never Events between March 2023 and April 2024 was University Hospitals Birmingham NHS Foundation Trust. They recorded 11 Never Events in total. The trust also recorded the highest number of Never Events in 2022/23, where they recorded 10.

Behind them, St George’s University Hospitals NHS Foundation Trust in London, The Newcastle Upon Tyne Hospitals NHS Foundation Trust and University Hospital Southampton NHS Foundation Trust all recorded 10 never events between March 2023 and April 2024.

Barts Health NHS Trust also in London followed behind with 8 Never Events in total.

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

1. University Hospitals Birmingham NHS Foundation Trust – 11
2. St George’s University Hospitals NHS Foundation Trust – 10
3. The Newcastle Upon Tyne Hospitals NHS Foundation Trust – 10
4. University Hospital Southampton NHS Foundation Trust – 10
5. Barts Health NHS Trust – 8
6. Calderdale And Huddersfield NHS Foundation Trust – 7
7. East Kent Hospitals University NHS Foundation Trust – 7
8. Kingston Hospital NHS Foundation Trust – 7
9. University Hospitals Coventry And Warwickshire NHS Trust – 7
10. Barking, Havering And Redbridge University Hospitals NHS Trust – 7

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.