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NHS 'Never Events 2021/22

26 May 2022

"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. Between April 2021 and March 2022, there were nearly eight of these events every week.

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The NHS has set out that 'Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.'

407 Serious Incidents met the definition of a Never Event in the Never Events list 2018 (published 28 February 2018) and had an incident date between 1 April 2021 and 31 March 2022. These Never Events included:

  • Injections to the wrong eye
  • The removal of ovaries when the surgical plan was to conserve them
  • 98 instances of retained foreign object post-procedure including; vaginal swabs, bolts, wires, screws and parts of a wire cutter.
  • Biopsy from wrong kidney
  • Procedure to a breast that had not been consented
  • Wrong side spinal surgery
  • Toe procedure intended for another patient

The full list can be found here

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.

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