BBC: 750 ‘never’ events in the NHS last year. Terrible?

The BBC is reporting today that some 750 ‘never incidents’ – incidents that the Dept of Health says ‘should never happen’ – occurred in 2012/13. These incidents include such things as clamps or gauze left inside a patient after an operation, or operations being carried out on the wrong body part.

Radio 4’s feature on the statistics included an interview from a woman whose mother died after a feeding tube went into her lung rather than her stomach, which is a terrible tragedy for the family involved, but does this make the NHS a bad health service, or represent a serious problem on a ‘macro’ scale?

750 sounds like a lot. However, according to an NHS spokesperson, this total represents 4 out of every 100,000 procedures – or 0.004%. You’re around 2.5 times more likely to be killed in a road accident on any given day than you are to suffer a ‘never incident’ if you have to be treated in hospital – and most of those incidents are not fatal or even permanently damaging.

It appears to be open season on the NHS at the moment. Of course, every practitioner in every hospital should always be working to improve systems and procedures to ensure that any untoward incidents are minimised. But by headlining a figure that seems large out of context (context is, after all, everything and statistics can easily mislead), the BBC is adding to the tidal wave of misrepresented information currently eroding public confidence, when the facts in context suggest that going into an NHS hospital for an operation is as near to completely safe as any medical intervention anywhere could be.

You see, calling them ‘never events’ is never going to mean that they never happen (so much for never say ‘never’!). They are things you never want to happen and should never just accept – but they’re always going to happen, because with the best will in the world, to err is still human. That they happen in 4/1000ths of a percent of the time means the NHS is bloody good, especially when you consider the chronic and increasing understaffing and overwork being inflicted on it by this government – and any headline or article even hinting otherwise should be dismissed for the disingenuous tosh it is.

If you watch NHS-related news coverage carefully, as I do, it’s almost impossible not to conclude that this is a co-ordinated effort. It’s not hard to work out why.


  1. Couldn’t agree more. Can we even find out how many “never events” happen in the private sector?

  2. The definition of a never event is an error that results in severe harm or death. Therefore, your claim that “most of those incidents are not fatal or even permanently damaging” seems misleading. It’s in the hospital interest to keep the numbers down so they would not include trivial incidents.

    1. A clamp or other ‘leftover’ remaining in the body cavity after an op would qualify as a ‘never’ incident even if no serious harm resulted, as I understand it. It’s more about the nature of the error than the consequences.

      1. It probably depends on how you classify serious harm. To me the fact that I would need to be re-operated (every surgery is risky), be at a risk of an infection and have to take even more time to recuperate is enough. Here’s guidelines about never events: http://bit.ly/11VfVAf

    2. From https://www.gov.uk/government/news/never-events-list-update-for-2012-13:

      The full ‘never events’ list for reference is:

      -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-naive 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.

      Clearly some of these are inevitably harmful or fatal – but some are ‘never events’ merely by the fact of their occurrence, regardless of the consequences.

  3. I used to really like the BBC, tbh its still capable of producing some of the best telly on the box. But from a news perspective they are little more than a Govt mouthpiece and not really to be trusted.

  4. Compare that figure to the deaths attributed to AtoS and the D.W.P. Mistakes do happen and when you take into account the hours worked by our under staffed, over worked, real health care professionals although these mistakes should not happen they could possibly be forgiven. After all they are not on a bonus for destroying someones life unlike the unethical, plastic HPCs the D.W.P and AtoS use are they

  5. It’s all really a lot more complex than that.

    Iatrogenic (i.e., caused by the medical system itself) harm is actually a fairly substantial problem in all health care systems. You can argue about whether this or that underlying system (free, or single-payer like in France, or a US-style insurance-based system, etc etc) makes these things more or less likely, and it is of course unfair to rubbish the NHS as if this kind of thing wouldn’t be pretty much equally likely to happen in any other system or country.

    That said, the culture of the medical profession (again, in pretty much every country) could do with learning – a lot – from the aviation industry, a sector which arguably attracts even more macho know-it-alls than surgery, but which has constantly improved its safety record over the years by taking every little detail seriously. Their idea of a “should never happen” incident is two planes coming within several hundred feet of each other.

    1. It’s a completely different context, though. Go the way you’re suggesting and surgeons will face perverse pressure never to undertake a risky procedure that might reflect badly on them or their hospital, even if it means leaving a patient to die a ‘risk-free’ death. Health-care can never be ‘zero-harm’ – not in real life, nor are we better off if it is. I agree every reasonable safety precaution should be taken, but the degree of caution appropriate to aviation won’t be fitting in every healthcare circumstance.

      1. I don’t agree. Most of the items on that list are nothing to do with the riskiness of the operation (where I do agree that the whole “league table” thing has substantial downsides). But amputating the wrong leg or misidentifying patients is the equivalent of taking off with no fuel on the plane.

        I feel that this post is not a fruitful way to defend the NHS (of which I am a fan). There are going to be cock-ups, and to the extent that some of those are due to management and corporate culture, that should be addressed. But to suggest that for the BBC to flag up this story, which is obvious public interest, makes it into Jeremy Hunt’s PR department, is taking things a little too far. Right now I’ve heard the headline “Ministers admit A&Es are struggling to cope with demand”; hardly a Pravda-type line. (I’m at least a big a fan of the BBC as of the NHS, and I note that the BBC is attacked more or less equally from left and right as being a tool of the other side. I work on the basis that this means they’re probably doing something right.)

      2. Apparently the 750/760 figure relates to a 4-year period, so we’re talking about an incidence-rate of 0.001%. I don’t know the aviation industry’s figures off the top of my head, but I doubt they’re any better – and remember, a lot of the included incidents have nothing to do with quality of care (e.g. escaped prisoners or suicides by self-hanging).

        I stand by my point – a molehill turned into a mountain for ulterior motives.

  6. Even the figure of 4 out of 100,000 procedures is misleading – when you factor in the number of non-procedural patients that go through NHS care during the period that 100,000 procedures take place. Add to this the highly suspect non-procedural ‘never’ events:

    -suicide using non-collapsible rails
    -escape of a transferred prisoner
    -falls from unrestricted windows
    -entrapment in bedrails

    Our doctors and nurses cannot be expected to be prison guards, nor monitor every patient 24/7 in case they harm themselves or have an accident. Aside from the escaping prisoners – which is a police responsibility – the others are closer to ‘inevitable’ events, as wherever human beings are a number of them will suffer accidents.

  7. The BBC news Heath section does give it some context although they take a few paragraphs to make the point. 762 incidences over 4 years. Roughly 190 per year. Admissions leading to surgery 4.6 million per year. 190 out of 4.6 million. Why is this even news. Surgeons are humans they make mistakes,they don’t mean to but they happen. As long as they are rare then it’s unfortunate/ bad luck if its you but it’s just one of those things.

  8. Totally agree. It’s depressingly predictable that these events, which should have been reported at the time, are all flooding out just when the Government has forced through a bill that would otherwise have certainly left them,unelectable. Also predictable is that nowhere in any story about how the NHS is struggling can i find a reference to the effects of the Health and Social Care Act.

  9. This is manipulation. Words are strong and effective. Words are powerful. The Government use language for good or bad. They are trying to erase “disability” and replace it with “independence”. No big deal until the truth sets in. If you can’t be independent and be useful then that’s it. Language is a powerful thing…beautiful, emotive, inspiring…but in power hungry politics it becomes a trick…lies coated with sugar. Beware.

  10. Again .. Use of language is good for deniability. Lawyers love it. It kind of excuses human error.. And then who do you blame when gran starves in a nursing home..a stressed mental health patient breaks down..or you are still three trolleys away from a doctor in A +E . I will never blame the staff…I was a nurse.
    Just see what is happening!
    If you undermine a service to the point of ridicule and howls of criticism..it is a perfect ground for dismantling and destruction. This is the Tory goal.

  11. Actually I think there have been several attempts to emulate the aviation industry (i.e. reporting/looking into all near misses, procedural errors as well as harmful events and learning from them). The problem is that you need no-blame reporting (i.e. disciplinary action does not result from honest reporting) – and NHS managers just can’t accept that.
    One of the hospitals closest to this is Stafford. Doctors have been known to report their own drug errors and nurses report things that never happened but they feel might well have – and actually these can be very informative. If you could get the blame out of the NHS culture it would go a long way to improving safety. Ironically the very people baying for a safer NHS (HMG, the Media, pressure groups) are themselves preventing it by perpetuating the wrong culture.
    As you say, despite this, the NHS is remarkably safe. If you peruse the world literature on patient safety, 2 things stand out. Having up-to-date, correct, clear, locally owned procedures and protocols in place and teamwork. The professions are pretty good at sharing good ideas and practice (it’s the managers that compete) and the vast majority of clinical teams are very cohesive. (Mind you, we are never satisfied – another helpful attribute).
    Well done everybody!

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