Never Events - When Surgery Goes Wrong

Rebecca Brunton
Medical Negligence Solicitor

Having surgery is always a worrying time given the associated risks. As standard practice, patients will be asked to sign a consent form setting out the most significant complications that could occur, before having the surgery. When consenting to the surgery, the patient trusts that their surgeon will provide them with the best possible care, and that they’ll take all reasonable steps to avoid any complications occurring. 

Sometimes, however, a surgical procedure does go wrong in a way that a patient would never have expected, such as a surgeon operating on the wrong leg. This surgical error would fall within the list of potential incidents classified by the NHS as ‘Never Events’. As the name suggests, these are incidents that should never occur. 

If you have been affected by a so-called Never Event, you may be able to claim compensation for medical negligence. For free legal advice get in touch with our Medical Negligence Solicitors – ask if we can deal with your claim on a No Win, No Fee basis.

Call us on 0808 239 6043 or request a callback

How Common are Never Events?

The NHS publishes information on Never Events which have taken place. The most recent publication confirms that between 1 April 2018 and 31 January 2019, there were 423 Never Events, including:

      • 165 incidents of surgery on the wrong site including operating on the wrong leg, as well as operating on wrong side of a patient’s knee, doing an injection into the wrong eye, removal of the wrong tooth or taking a biopsy from the wrong place. Alarmingly, it also includes operations on the wrong patient
      • 91 incidents where surgical instruments were left inside patients at the end of surgery
      • 58 incidents where patients were given the wrong implant/prosthesis, such as the wrong hip replacement.

        For the full NHS list see Never Events data.

Never Events in the NHS

Clearly, Never Events in the NHS are continuing to happen on a regular basis throughout the UK. The causes for Never Events may be various; from a failure to follow national guidance and safety recommendations, to poor communication, human error and plain carelessness.

Whatever the reason, a Never Event will almost always be a breach of the duty of care owed to a patient by their doctor or surgeon. Where surgical errors occur, the consequences for the patient can be very serious, and will often result in a need for further surgery, along with a prolonged recovery period and a worse overall outcome. In these cases, a Surgical Error Claim for compensation should be started as soon as possible.

In the example of operating on the wrong leg, this surgical error should be avoided by the checks a patient goes through before surgery, including:

      • Clinic appointments
      • Pre-operative assessment
      • Speaking to medical staff and the surgeon on the day of the surgery
      • Marking up of the leg whilst the patient is waiting to go into theatre

If, during the pre-operative assessment, the clinician accidentally writes ‘L leg’ instead of ‘R leg’ or if their handwriting isn’t clear, this could lead to surgery being carried out on the wrong leg; particularly if the surgeon doesn’t check the notes or speak with the patient on the day of the procedure.

As a result of this Never Event, the patient would need to have further surgery on the correct leg. However, a period of time might be needed between the surgeries in order to minimise certain risks associated with the anaesthetic and reduced post-operative mobility.

The patient would have to endure a painful and prolonged recovery period for both legs, and as a result, they may incur a loss of earnings, and need to rely on family and friends for help with day-to-day tasks.

Every time a Never Event occurs, the NHS Trust concerned is expected to carry out an internal investigation in order to identify the cause, and to take preventative action so that similar events don’t happen again in the future. Whilst this is a positive step, the fact that Never Events continue to occur is evidence that NHS Trusts are simply not learning from their mistakes and patients are continuing to suffer life changing surgical errors as a result.

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