Safety watchdog says NHS ‘never event’ mistakes are not yet truly preventable

At least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said.

The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening.

The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth.

Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach.

In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19.

NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen.

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Source: The Independent, 21 January 2021