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Care Quality Commission publish report on NHS Never Events

The Care Quality Commission (CQC) recently published a report that focused assessing the number and type of never events in NHS hospitals around the UK.

The CQC describes never events as "serious, largely preventable safety incidents that should not occur if the available preventative measures are implemented" and they include incidents such as wrong site surgery, or foreign objects left in a patient’s body following an operation. The NHS currently lists a total of 15 incidences as never events on their website, with a sixteenth - undetected oesophageal intubation - temporarily suspended from the list last year. The current never events listed include:

  • Wrong site surgery
  • Wrong implant/prosthesis
  • Retained foreign object post procedure
  • Mis-selection of a strong potassium solution
  • Administration of medication by the wrong route
  • Overdose of insulin due to abbreviations or incorrect device
  • Overdose of methotrexate for non-cancer treatment
  • Failure to install functional collapsible shower or curtain rails
  • Mis-selection of high strength midazolam during conscious sedation
  • Falls from poorly restricted windows
  • Chest or neck entrapment in bed rails
  • Transfusion or transplantation of ABO-incompatible blood components or organs
  • Misplaced naso- or oro-gastric tubes
  • Scalding of patients
  • Unintentional connection of a patient requiring oxygen to an air flowmeter

The CQC report found that the ‘most common’ type of never event to occur across NHS Trusts in England during that period was wrong site surgery - where surgery is performed on the wrong person, or on the wrong part of the body.

However, the report also investigated the reasons as to why such incidents are occurring. According to the data, staff are struggling to cope with the large volumes of safety guidance they receive and complain of having little time and space to implement such guidance effectively. The report added that NHS staff feel that the systems and processes around them are not always supportive.

Where staff are trying to implement guidance, the CQC found that they are often doing so on top of a demanding and busy role, which means it is difficult to give the work the time it requires.

In terms of the wider system, the report found that the 'different parts at national, regional and local level don't always work together in the most supportive way'. Staff reported a lot of confusion surrounding the roles of various bodies and where exactly trusts can go to seek the most appropriate support.

Furthermore, the report found that education and training for patient safety could be 'significantly improved', adding that NHS staff are simply not receiving the necessary training required at undergraduate level or they are not given enough time to carry out appropriate levels of training on patient safety after commencing their clinical careers.

Whilst never events are rare, with just 469 provisionally reported between April 2017 and March 2018, incidents can have devastating and often life-long consequences for the patient and their family.

Sophie Birch, Clinical Negligence Solicitor here at Potter Rees Dolan, comments:

The occurrence of never events and the reported lack of support available to medical staff is concerning. The CQC’s report identifies that education and training to staff could be significantly improved and I am interested to see what steps are being taken to address these concerns given that patient safety is paramount.

Take a look at some of our recently settled Clinical Negligence cases here.

Sophie Birch is a Clinical Negligence Solicitor at Potter Rees Dolan. Should you have any queries regarding clinical negligence, serious injuries or indeed any other aspect of this article and wish to speak to Sophie, or any other member of the team, please contact us on 0161 237 5888 or email Sophie directly.