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18.02.16

Never events in English hospitals reach 1,188 in four years

‘Never events’, such as patients having the wrong organ removed or foreign bodies left inside them, in English hospitals reached 1,188 in the period 2012-16.

NHS England figures show that there were 290 never events, defined as preventable incidents with the potential to cause serious harm or death, from 1 April 2012 to 31 March 2013 and 338 in the same period from 2013 to 2014.

There was then a decline to 306 (originally reported as 308) from 1 April 2014 to March 31 2015, but this appears to have been reversed. There are provisionally thought to be 254 never events from 1 April to 31 December 2015 alone.

Katherine Murphy, chief executive of the Patients Association, said: “It is a disgrace that such supposed ‘never’ incidents are still so prevalent. With all the systems and procedures that are in place within the NHS, how are such basic, avoidable mistakes still happening? There is clearly a lack of learning in the NHS.

“These 1,100 patients have been very badly let down by utter carelessness. It is especially unforgivable to operate on the wrong organ, and many such mistakes can never be rectified.”

In 2014-15 the biggest complaint was wrong site surgery, with 124 incidents reported, including one patient who had a kidney removed instead of an ovary, a woman who had a fallopian tube removed instead her appendix, and one man having an entire testicle removed instead of a cyst.

Patients also had the wrong leg, hip and area of breast removed, and eight patients had the wrong eye removed.

Foreign objects were left in 102 patients after surgery, and other problems included patients being misidentified or given the wrong medication, wrongly prepared injectable chemotherapy and transferred prisoners escaping.

Colchester Hospital University NHS Foundation Trust had the highest number of events in the 2014-15 period with nine in total – five foreign objects retained, three wrong site surgeries and one wrong implant/prosthesis.

“One never event is too many and we mustn’t underestimate the effect on the patients concerned,” said a spokesperson for NHS England.

“However there are 4.6 million hospital admissions that lead to surgical care each year and, despite stringent measures put in place, on rare occasions, these incidents do occur.”

She added that the NHS published new National Safety Standards for Invasive Procedures (NatSSIPS) in September 2015 to avoid never events and that any organisation that reports a serious incident is also expected to conduct its own investigation.

 

 

 

 

 

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