The occurrence of 'never events' leads Croydon Health Services NHS Trust to change its procedures

Posted: 04/06/2013

For some years the NHS has maintained a list of ‘never events’, which are events that are considered to be so serious that they should never occur in the context of NHS treatment.

The list originally included seven events, such as the performance of wrong site surgery, using the wrong route of administration for chemotherapy and the retention of foreign objects post-operation, but was extended a couple of years ago to encompass an additional 18 events, including the use of the wrong implant/prosthesis; entrapment in bedrails; air embolism and maternal death due to post-partum haemorrhage after elective caesarean section.

It has recently been reported that Croydon Health Services NHS Trust is changing its procedures as a result of eight patients falling victim to four of these never events at Croydon University Hospital. Specifically, it is reported that, over the past four years, three patients have been left with foreign objects inside them post-operatively; two patients have had surgery performed in the wrong place; there have been two occasions when the wrong implants have been used and one incident of a mother dying following childbirth.

Zoe Packman, Director of Nursing at the trust, told the Croydon Guardian that a number of actions are being taken to prevent these incidents happening again including ensuring that surgical safety checklists are always completed for surgical procedures; recording, in detail, the supplies used during surgery; double checking procedures for implants before they are used and retraining staff.

As a firm, we are all too frequently asked to advise in cases where never events have occurred. It is hoped that a proactive approach by the NHS to recording such events, a willingness to learn from these mistakes and changes being made to procedures to ensure that such events are not repeated will lead to improved patient safety.

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