“Never events” is the name given to things so serious that they should never happen – but in the NHS in England, there were 407 of them in a year.
Never Events are “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations”.
Between April 2021 and March 2022, there were nearly eight of these events every week – up from the seven-per-week seen the previous year, according to figures analysed by the PA news agency.
Among the 407 events, there were 98 cases of a foreign object being left inside a patient by mistake – vaginal swabs were left in patients 32 times and surgical swabs were left 21 times.
Other items included a pair of wire cutters, part of a scalpel blade, and the bolt from surgical forceps.
There were three occasions when part of a drill bit was left inside a patient.
One woman had her ovaries removed by mistake
Also, there were 171 cases of surgery being done on the wrong body parts – one woman had her ovaries removed by mistake, six patients had injections to the wrong eye.
The wrong hip implant was done 12 times, a wrong knee implant was done 11 times, and patients were connected to air instead of oxygen 13 times.
Seven people received the wrong blood type in a transfusion and one patient had a breast procedure they had not consented to.
A further 29 cases fell under the “serious incidents” category and are being investigated, so may yet be re-classified as “never events”.
“Serious physical and psychological impact on patients”
Manchester University NHS Foundation Trust reported 11 errors; Nottingham University Hospitals NHS Trust and Sandwell and West Birmingham University Hospitals NHS Trust both reported 10; Gloucestershire Hospitals NHS Foundation Trust, Liverpool University Hospitals NHS Foundation Trust and University Hospitals of Leicester NHS Trust, and Worcestershire Acute Hospitals NHS Trust, all reported nine.
An NHS spokesperson said: “While these events are extremely rare, and NHS staff are working hard to provide safe care to patients, it is important that events are reported and learned from so that they can be prevented in the future.”
A Department of Health and Social Care spokesperson said: “Patient safety is a top priority for the government and these unfortunate events – although very rare – can have a serious physical and psychological impact on patients.
“We are implementing the NHS Patient Safety Strategy which is designed to support staff to provide safe care and learn lessons.
“There are record numbers of nurses, doctors and overall staff working in the NHS, and we have set out our plan to tackle the COVID backlog, backed by record investment.”