THE BLOG
17/09/2013 09:29 BST | Updated 17/11/2013 05:12 GMT

Rise in Hospital 'Never Events' Is a Real Concern Whichever Way You Look at It

The sharp rise in the reported number of patients suffering 'never events' - events that should never happen, some of which are potentially fatal - over the past year is deeply concerning, even if some of it may be down to more accurate reporting.

According to the Department of Health, the number of 'never events' reported by NHS service providers in 2011/2012 was 299, up from 163 in the previous year - an 84% increase.

It is probably true that better awareness of healthcare failings is leading to more accurate reporting of such events, but this should not prevent us from recognising these statistics for what they are - inexcusable and avoidable mistakes that have had terrible consequences for patients.

The Department of Health's decision to publish details about the number of 'never events' in the past year is nothing new. However, from next month, NHS trusts will be required to publish such errors on a quarterly basis for each hospital. In doing so, the intention is to give the public more information and to increase transparency.

The list of 'never events' published by the Department of Health includes events such as wrong-site surgery and wrongly prepared high-risk medication. The list was extended in 2011 to include events such as transfusing the wrong type of blood and misidentifying patients due to the failure of wristband identification being used. Of the 25 'never events' on the list, the four most common to occur are foreign objects left inside patients during operations, surgery performed on the wrong part of the body, feeding tubes inserted into patients' lungs and wrong implants or prostheses being fitted.

Access to such data is clearly important, but at a time when more information is being shared with the public, there is growing concern that we may not appreciate its significance or how to prioritise it against other information.

A high incidence of 'never events' is a worrying indication that a poor standard of care exists at a certain hospital and it is potentially more significant than data about the death rates attributed to individual consultants. When it comes to the performance of individual consultants, for example, death rates could be high simply because they perform high-risk procedures. 'Never events' should be considered more significant because they are unacceptable and eminently preventable mistakes leading to serious outcomes for patients.

While it may be somewhat true, it is not helpful for the increase in 'never events' to be explained away as more accurate reporting. Ministers and healthcare managers alike need to accept that adopting a culture of openness and honesty in the NHS will inevitably mean being prepared to talk about the bad results.

This follows the review into patient safety by Professor Berwick, published in early August 2013, which recognised that transparency is essential in the NHS. It also recommended that quantitative targets should be used with caution, as the focus should always be on better patient care.

This is certainly the case with some targets that had been set in the past. However, it is important that sufficient gravity is given to the records of 'never events' as these are the very worst episodes of substandard care being provided. These events must be the trigger for learning every time they occur, not just when a pattern occurs, or when the number of events reaches a certain level.

I hope that this new data will inspire some action in every hospital where a 'never event' has occurred. We need to seek assurances that steps are being taken to prevent 'never events' from happening in the future and crucially need to see numbers start to fall. In the meantime, patients who suffer because of such failings should not be deterred from bringing a claim for compensation. At my firm, we are currently investigating five claims where 'never events' occurred, including two where foreign objects were retained after surgery. Given their nature, such claims are likely to succeed.

Suzanne Trask is a partner and medical negligence specialist at Bolt Burdon Kemp - www.boltburdonkemp.co.uk