Never Events in the NHS

Jodi Newton

The NHS performs over 7 million surgical procedures every year, and the vast majority of these are successful. However, occasionally something goes wrong, sometimes due to the negligence of the medical professionals responsible for the patient’s care. Whilst some errors can be rectified quickly and with little adverse effect on the patient, some errors can have devastating and life-changing consequences.

What Are Never Events?

The NHS defines so-called Never Events as “serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers”. NHS England has developed a list of Never Events which are periodically reviewed and which were last updated in February 2021.

Examples of never events include:

• performing surgery at the wrong site;
• retained foreign objects following a surgical procedure;
• administering certain medication through the wrong route;
• patient falls from a poorly restricted window;
• misplaced nasogastric or oro-gastric tubes.

Can you claim compensation for Never Events?

Hospitals have policies and frameworks in place to investigate serious incidents, including never events. Under the duty of candour healthcare providers have a statutory duty to be open and honest with patients when things go wrong during their care.

Never events should, quite simply, never happen if guidance or safety recommendations at a national level are properly implemented. If you have experienced a never event during your medical treatment it may be possible to claim compensation. The NHS has a structured complaints procedure that allows patients or their families to raise concerns about never events. The NHS Complaints Procedure provides a formal way to ensure your grievances are heard and addressed.

Case Studies: The Impact of Never Events

Removal of fallopian tube on the wrong side

One such never event reported recently was the case of 27-year-old Chelsie Thomas, who was admitted to Walsall Manor Hospital in March 2018 suffering from an ectopic pregnancy. Miss Thomas was booked in for a procedure to remove her right fallopian tube, however, she was informed one week following the procedure that the doctor had accidentally removed the left fallopian tube. As a result, Miss Thomas was taken back to the operating theatre the following morning for her right fallopian tube to be removed. Miss Thomas has been told that she will be unable to have children in future without IVF treatment.

Whilst the Trust responsible for managing the hospital apologised for this error, the wider effect on Miss Thomas’s life has been devastating. She has been diagnosed with severe depression for which she is taking anti-depressants, her relationship with her partner broke down, and she has lost her job.

It is clear in the above case that the surgery was carried out without due diligence and attention from the surgeon concerned. Miss Thomas will, as a result of what has happened, be entitled to pursue a claim against the Trust concerned and whilst money cannot adequately compensate for what has happened, it can assist those who have suffered as a result of clinical negligence in accessing things like future treatment.

Staple left in man’s shoulder

One such case which we dealt with involved a 33 year old man who had a history of repeated episodes of shoulder dislocation. He was referred to an orthopaedic surgeon at University College London Hospital in Euston and was booked in for surgical management in the form of a stabilisation procedure.

Our client underwent a bone block with an anterior stabilisation procedure on 6 July 2016 and he was told that there were no complications during the surgery. However, in the weeks following the procedure our client experienced redness and swelling on and around the wound on his shoulder, which appeared to be infected. An x-ray was undertaken, and there appeared to be no concerns.

On 21 July 2016, our client noticed that the skin on the surface of the wound had broken and puss was oozing from the wound. The pain and discomfort in his shoulder continued and eventually our client attended A&E on 22 July 2016. He was told he was suffering from a superficial wound infection and discharged on antibiotics.

Our client was reviewed again in the clinic on 28 July 2016 and it was noted that there was some pus being expressed from the wound. A swab was sent, our client was advised to continue taking his antibiotics and he was booked for a follow up in August 2016.

On attending the follow-up appointment on 4 August 2016, our client was reviewed by the consultant and it was noted his wound was improving but not completely closed. The consultant reviewed our client’s x-ray taken on 21 July 2016 and noted that this showed that a surgical staple remained in the shoulder at the level of the wound and had become infected. He was booked in for surgery the following day under a general anaesthetic to remove the staple from his shoulder.

A Letter of Claim was sent to the Trust, which promptly admitted liability for our client’s claim, and after a period of negotiation, a financial settlement was achieved.

Whilst the consequences, in this case, were relatively mild, some never events can have fatal consequences.

Fatality due to failure to provide medication

Osbornes Law recently acted in a clinical negligence claim brought by the son of a 78-year-old lady who sadly passed away as a result of a never event at the Whittington Hospital in London.

Mrs DS first presented at the A&E department at Whittington Hospital on 31 August 2016 complaining of a 3-week history of shortness of breath and reduced exercise tolerance. A CT scan was performed which showed that she was suffering from bilateral pulmonary emboli. She was commenced on a treatment dose of Tinzaparin (blood thinning medication) and kept in hospital overnight. It was noted by the hospital that Mrs DS’s home life was chaotic and that her compliance with her required medication regime could be low. It was explained to Mrs DS that if she did not take her medication she could die, however, given the doctors’ concerns she was persuaded to remain as an inpatient for treatment.

However, Mrs DS was keen to discharge herself and eventually on 5 September 2016, following a review by the mental health liaison team, she was deemed fit for discharge. Her son was not informed of her discharge and believed she was still in hospital. Mrs DS was discharged on Tinzaparin to be administered subcutaneously each afternoon by a district nurse at 2 p.m. for 28 days and a referral was made to the district nurse accordingly. Mrs DS was not given the telephone number of the district nurses, and was not told to call anyone if the district nurse failed to attend the following day.

Despite the referral having been attempted, an obsolete email address that had not been deleted from the computer system was used by the Whittington Hospital to make the district nurse referral, and as a result of this error, the referral was never received by the district nurses. No follow up letter or telephone call was made to the district nurses.

As a result of this, a district nurse failed to attend Mrs DS following her discharge from the Whittington Hospital on 5 September 2016. Mrs DS, therefore, did not receive the required injections of Tinzaparin on 5 September 2016, nor on any subsequent day leading up to her death on 15 September 2016.

On the evening of 14 September 2016, Mrs DS collapsed at home. Her son was at home with her but in a different room. He ran to her assistance. Mrs DS’s home landline was not in working order and so her son ran next door to her neighbour who telephoned for an ambulance immediately. An ambulance arrived within approximately 15 minutes and Mrs DS was taken to the Whittington Hospital.

On arrival at the hospital, the medical and nursing staff at the Whittington Hospital were unable to revive Mrs DS and she was pronounced dead shortly thereafter. The cause of death was noted to be pulmonary thromboembolism.

An inquest was subsequently held into Mrs DS’s death and the coroner found that had she received the Tinzaparin as prescribed for the preceding ten days, Mrs DS would not have died when she did.

Osbornes wrote a Letter of Claim to the Trust and four months later admission of liability was received. Negotiations commenced and eventually, a five-figure settlement was achieved on behalf of Mrs DS’ son. In order to receive the compensation Mrs DS’ son was required to obtain a Grant of Probate in order to be appointed as the representative of his late mother’s estate, and the Private Client team at Osbornes were able to assist him with this process.

Legal Support

At Osbornes Law we care about how you are treated both by medical professionals at your GP surgery or at hospital and also under the care of private providers of health services. We have many years’ experience of dealing with claims under the Fatal Accidents Act 1976 and the Law Reform (Miscellaneous Provisions) Act 1934, and our Private Client Department can assist in obtaining a Grant of Probate/Letters of Administration.

If you think that the care you or a loved one has received fell below the standard expected of a reasonably competent professional, then please do not hesitate to contact Partner and specialist medical negligence lawyer Stephanie Prior on 020 7681 8671.