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Medical Mishaps That Should Never Happen: NHS Framework Under Fire


NHS England (NHSE) has launched a consultation on the future of its never events framework, seeking views on whether it is an effective mechanism to drive patient safety improvement. 


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 policy was introduced in 2013 in the hope of preventing the most serious of medical mishaps, such as wrong site or even wrong patient procedures, retained foreign bodies after surgery, and catastrophic medicine errors. However, hundreds of never events continue to be reported annually, and the framework has been extensively criticised.


System Is ‘Confused and Complex’

A 2018 report by the Care Quality Commission (CQC) described the never events system as "confused and complex, with no clear understanding of how it is organised and who is responsible for what". 


It said that staff struggled to cope with "large volumes of safety guidance" that they had insufficient time and space to implement effectively. Systems and processes were not always supportive; national, regional, and local level organisations did not always work well together; there was confusion about the roles of different bodies and where trusts could access the most appropriate support; and education and training for patient safety needed significant improvement.


Too Many Patients Still Suffer Harm

At the time, CQC’s chief inspector of hospitals, Professor Ted Baker, said in a statement that despite the best efforts of NHS staff, never events and other patient safety incidents continued to happen. "In theory, these events are entirely preventable. In practice, too many patients suffer harm."


A report by the Health Services Safety Investigations Body (HSSIB) in 2021 detailed 10 investigations into never events that had nonetheless occurred. It found widespread local variation in key safety-critical processes, and urged NHSE and NHS Improvement to review and revise the list, and to commission programmes to find strong and systemic barriers for specific incidents where barriers were felt to be possible but not currently available.


For 2022/2023, recorded never events included:

  • Wrong site surgery

  • Retained foreign object postprocedure

  • Wrong implant/prosthesis

  • Misplaced nasal or oral gastric feeding tubes

  • Wrong route medicine administration

  • Overdoses – insulin, methotrexate

  • Mis-selections – strong potassium solution, midazolam strength

  • Transfusion/transplantation of ABO-incompatible blood components/organs

  • Falls from poorly restricted windows

  • Chest or neck entrapment in bed rails

  • Scalding of patients

Just last week, the latest HSSIB investigation noted that, despite previous interventions, patient misidentification continues to pose a persistent safety risk throughout the NHS.


Emphasis on Never Events List 'Unhelpful'

Dr Mike Devlin, head of professional standards and liaison at the Medical Defence Union (MDU), has previously argued that the framework has had a limited effect on patient safety. He criticised the "reductive concept" of never events, saying that the emphasis on a limited list of specified errors is unhelpful, paradoxically deflecting attention from improving safety across the board. 

He told Medscape News UK that the MDU welcomed the consultation on the never events framework and looked forward to reviewing it and responding to the points raised on behalf of its members. 


"We have pointed out previously the shortcomings in the current system, namely that these events continue to occur despite the efforts of clinical staff to avoid them, and that the focus on certain events over others is not helpful in improving patient safety generally," he said. "It can also lead to unfair stigma and blame for those involved in never events."

Also speaking to Medscape News UK, Andrew Ford, CQC’s deputy director of secondary and specialist healthcare, said: "We welcome the consultation launched by NHS England on the never events framework. We will be considering the proposals carefully and will respond in full with our feedback."


Reform Options

NHSE said the consultation was being held following the findings of the CQC and HSSIB reports, as well as further focus groups held by its National Patient Safety Team throughout 2021/2022. It asks whether the list is an effective mechanism to drive safety improvements, and offers four possible reform options:


  • No change

  • Revise the list to only include events with current barriers that are strong, systemic, and protective

  • Create a new system with revised definitions that do not require all incidents to be wholly preventable

  • Complete abolition of the never events framework and list

The consultation will last for 12 weeks and is open to responses until 5 May.

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