Never Events in the NHS

Stephanie Prior
Explaining NHS Never Events

Contact

Table of Contents

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. 

Share this article

Contact us today

For a free initial conversation call 020 7485 8811

Email us Send us an email and we’ll get back to you






    More from StephanieVIEW ALL

    1. women and cardiovascular disease
      1.10.2024

      Women are “under-treated” for Cardiovascular Disease

      Women are under-recognised and under-treated when it comes to cardiovascular disease Academics investigating the current state of the NHS have...

      Read more
    2. Vulnerable Patient - GP
      19.9.2024

      Vulnerable Patients at Risk due to Online GP...

      Vulnerable patients ‘locked out’ of GP practices due to online only system Being unable able to get a GP appointment...

      Read more
    3. surgeon
      12.9.2024

      Medical Negligence Investigation at Great Ormond Street Hospital

      Great Ormond Street Probe Underway Following a String of “Inappropriate and Unnecessary” Child Orthopaedic Surgeries An urgent review involving 721 children...

      Read more
    4. Landscape black and white
      10.9.2024

      Why are Suicidal Behaviours and Tendencies Overwhelmingly Ignored?

      Social media can often glamorise the idea of suicide, misleading young impressionable minds to romanticise suicide and encourage suicidal thoughts...

      Read more
    5. flowers in a field
      29.8.2024

      AB v Central London Community Healthcare NHS Trust

      Background Our client, AB, had been using the Nexplanon contraceptive device for 6 years. She had a Nexplanon device inserted into...

      Read more
    6. ICU
      30.7.2024

      Women in ICU Face High Risk of Stillbirth

      High stillbirth rates and repeated mistakes Researchers at the University of Edinburgh carried out numerous studies regarding pregnant women being...

      Read more
    7. Physician Associate
      30.7.2024

      What Is the Role Of a Physician Associate?

      What does the Position of Physician Associate Mean for the NHS? There are many different jobs within the NHS, each...

      Read more
    8. baby
      13.5.2024

      Birth Trauma Inquiry: Is poor maternity care the...

      Call for overhaul of maternity and post-natal care An All-Party Parliamentary Group has called for a huge overhaul of maternity...

      Read more
    9. supreme court ruling
      11.1.2024

      New UK Supreme Court Ruling regarding Secondary Victims...

      The Supreme Court has today, on the 11th January 2024, upheld the Court of Appeal’s order to dismiss the claims...

      Read more
    10. Supreme Court Ruling pic
      11.1.2024

      UK Supreme Court Ruling regarding Secondary Victims in...

      Introduction to the Supreme Court’s Decision on Secondary Victims in Clinical Negligence Cases The Supreme Court has today, on...

      Read more
    11. Ambulance UK
      12.12.2023

      NHS Compensation Payouts Guide

      What Are NHS Compensation Payouts? In the UK, the National Health Service delivers the vast majority of healthcare services. When...

      Read more
    12. hospital
      19.9.2023

      Appendicitis Compensation Claim

      Failure to diagnose appendicitis case settles for 5-figure sum Stephanie Prior was instructed in a claim against Bedfordshire Hospitals NHS...

      Read more
    13. model of a spine
      19.9.2023

      Spinal Fracture Case Settles for 6-figure Sum

      Spinal Fractures following cessation of Denosumab injection Case Overview Stephanie Prior was instructed in a spinal injury claim against Mid...

      Read more
    14. Ambulance vehicles at the Royal London Hospital
      10.8.2023

      Ambulance Delays Affecting Rapid Patient Treatment

      Failure to Meet Ambulance Response Targets In 2017, the Secretary of State for Health accepted the new ambulance performance standards recommended...

      Read more
    15. 5.6.2023

      Are pharmacy closures putting patients at risk?

      It has been reported in the press that chemist closures will have an impact on patients living in deprived or...

      Read more
    16. pregnant lady
      23.3.2023

      Private Pregnancy Scans and Substandard Care

      In the news, it has been reported that private clinics that offer pregnancy scans to women are not meeting the...

      Read more
    17. water
      9.2.2023

      Perineal Tear case settles for 6-figure sum

      Stephanie Prior recently settled a claim relating to a woman who delivered her baby after a traumatic labour. Her son...

      Read more
    18. hands of surgeon
      14.12.2022

      Successful settlement for negligent care during kidney transplant...

      Claimant v Royal Free London NHS Trust Osbornes have reached a settlement agreement on behalf of a Claimant who brought...

      Read more
    19. Hospital sign MATERNITY
      21.9.2022

      Are maternity services safe? – Part 2

      In April last year I wrote a piece about government setting up a taskforce to look into why there are...

      Read more
    20. asian old man devastated by bad news
      9.8.2022

      New interactive rating tool reveals NHS wait times...

      Amidst record-breaking heatwaves and a lengthy patient waiting list due to COVID backlogs, it is not surprising that this summer...

      Read more
    21. Medical doctor in empty hospital corridor
      1.8.2022

      Bereavement Following Treatment at Basildon Maternity Unit

      Case Overview Stephanie Prior’s death by medical negligence claim relating to the death of Gabriela Pintilie has been settled...

      Read more
    22. Insulin injection needle or pen for use by diabetics
      14.7.2022

      Insulin overdose in hospitals due to limited staff...

      A century ago, insulin was first used to treat a 14-year-old boy dying of type 1 diabetes. A hundred years later,...

      Read more
    23. NHS Building
      6.7.2022

      NHS aims to reduce waiting times with Elective...

      The NHS recently recorded their waiting list to be at 6.5 million, a record high. Much of this backlog is due...

      Read more
    24. doctor women at office
      29.6.2022

      Nottingham Maternity: Donna Ockenden to Chair Independent Inquiry

      An interim report on the state of maternity services at Nottingham University Hospitals NHS Trust has just been released. However,...

      Read more

    VIEW ALL