Preventable injuries to patients - the 'never event' update

1 November 2012

The Department of Health’s Update to its Never Events Policy Framework published on 29 October 2012 revealed that 326 Never Events occurred in the period 2011-2012.  Never Events are defined as “serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers”.  They are incidents which have the potential to cause serious harm or death.

The most commonly occurring Never Events for 2011-12 were: surgery being performed on the wrong part of the body (70 incidents); foreign objects being left inside patients’ bodies following surgery (161 incidents); and; the wrong implant or prosthesis being used (41 incidents).  All of these events are easily avoidable with the use of surgical checklists.  Such incidents have the potential to cause serious harm to patients, for example, retained swabs and packing can cause sepsis, retained screws or surgical tools can cause damage to internal organs and wrong implants or prosthetics, such as wrong sized replacement hips, can cause pain, reduced movement, further damage to the joint and the need for revision surgery. 

The document also sets out the 2012-13 list of Never Events which is as follows:

  • wrong site surgery
  • wrong implant/prosthesis
  • retained foreign object post-operation
  • wrongly prepared high-risk injectable medication
  • maladministration of potassium-containing solutions
  • wrong route administration of chemotherapy
  • wrong route administration of oral/enteral treatment
  • intravenous administration of epidural medication
  • maladministration of Insulin
  • overdose of midazolam during conscious sedation
  • opioid overdose of an opioid-naïve patient
  • inappropriate administration of daily oral methotrexate
  • suicide using non-collapsible rails
  • escape of a transferred prisoner
  • falls from unrestricted windows
  • entrapment in bedrails
  • transfusion of ABO-incompatible blood components
  • transplantation of ABO-incompatible organs as a result of error
  • misplaced naso- or oro-gastric tubes
  • wrong gas administered
  • failure to monitor and respond to oxygen saturation
  • air embolism
  • misidentification of patients
  • severe scalding of patients
  • maternal death due to post partum haemorrhage after elective Caesarean section.

Given the presumption made by the DoH, that such events should not occur if preventative measures have been taken, patients suffering adverse outcomes after suffering one of the above Never Events, will have good prospects of establishing liability in their clinical negligence claims.

If you would like advice regarding a potential claim, please contact the Clinical Negligence and Personal Injury team on 020 7814 1200 or by emailing us at 


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