NHS England is to publish quarterly details of “never events” on a trust by trust basis. This will allow the public to see how a particular trust performs on what is the very simplest patient safety.
A “never event” is something that should not happen. NICE publishes a list of these events annually. They include misplacing a naso-gastric feed causing the patient to drown in their food. The tube should go into the stomach but if it is misplaced can end up in the lung and if simple checks are not performed that error goes un-noticed. It is not negligent to misplace the feeding tube as it is done unsighted but it is negligent not to spot the error and rectify it immediately or at least before a feed is commenced.
Other examples of never events would include surgery on the wrong patient or to the wrong limb or organ. Such mistakes can often cause death or serious restriction on the patient’s independence. Leaving swabs in the patient’s body or leaving a surgical instrument in a body would also be examples of “never events”. All would amount to medical negligence or surgical negligence.
It is hoped that the new found commitment to openness and transparency will result in fewer of these but there are fears that pressures caused by cuts and reduced staffing levels will increase these mistakes. Only time will tell but many will read the published figures with interest. It is essential that trusts are honest in their reporting of such things so that standards can improve and one unintended consequence of this could be to drive down reporting levels to prevent what Jeremy Hunt describes as the “silent scandal” of the NHS getting any larger.
Whilst these “never events” are inexcusable as they are the most basic aspects of patient safety, they occur because of human error and anything that increases the risk of human error increases the risk of such mistakes occurring.
If you or a loved one has been affected by such a “never event” then you or your family member would be entitled to compensation for the resulting injuries and losses.