Scandal of the NHS's 'never-events' revealed

Scandal of the NHS ‘never-events’: Bungling hospital medics are wrongly removing ovaries and leaving drill bits INSIDE patients once a day, shocking audit reveals… so is YOUR trust one of the worst offenders?

  • EXCL: NHS medics are performing the wrong type of surgery 3 times per week
  • READ MORE: Health service adopts early warning system to prevent child deaths

Bungling NHS staff are carrying out the equivalent of one ‘never-event’ every day, figures show. 

This is despite the Government ordering a crackdown on the mistakes, which cost hospitals an estimated £800million in compensation each year. 

Experts today demanded further action on ‘unacceptable’ levels of never-events, blaming inadequate staffing levels and a lack of investment in the NHS. 

A MailOnline audit of a decade’s worth of NHS data found a colossal 4,328 never-events have occurred in England since 2013.

This equates to roughly eight a week. 

MailOnline’s audit of NHS data found a colossal 4,328 never-ever events have occurred in England since 2013, or eight a week. Source: NHS data

Here are the NHS trusts/private providers with the most never-events recorded in the past decade. Figures include health service organisations which have merged

Shocking incidents uncovered include women getting parts of their reproductive anatomy cut out instead of an appendix, men getting unwanted circumcisions and laser procedures to the wrong eye. 

Brits have also been left with scalpels, surgical gloves and even part of a condom inside them after surgery or other medical procedures. 

In one of the more peculiar incidents logged, a prisoner escaped while undergoing treatment. 

Officials have repeatedly decried the level of never-events occurring in the NHS and called for bosses to improve patient safety. 

In 2014, then-Health Secretary Jeremy Hunt ordered hospitals to drastically improve their safety record to reduce ‘not acceptable’ never events.

Retired police officer died after his head became trapped in his NHS hospital bed 

Max Dingle, 83, died 15 minutes after he was found ‘entrapped’ on a ward at the Royal Shrewsbury Hospital on May 3, 2020.

A coroner the death of a retired police officer, whose head became trapped between the rail and mattress of his hospital bed, was an ‘avoidable accident’

An inquest into Mr Dingle’s death found medics had not attempted resuscitation despite there being a pulse and the pensioner’s request for life-saving intervention.

Earlier this month, Shrewsbury and Telford Hospital NHS Trust, which runs the hospital, was fined a combined £1.3million for failing to provide safe care to Mr Dingle and another patient Mohammed Ismael Zaman who died in different circumstances.

Retired police officer Max Dingle, 83, died 15 minutes after he was found ‘entrapped’ on a ward at the Royal Shrewsbury Hospital on May 3, 2020

Senior coroner John Ellery said Mr Dingle, of Newtown in Powys, mid Wales, was originally admitted to hospital with ‘shortness of breath’ on April 27, 2020.

His medical history showed he had suffered with a heart condition, lymphoedema and sleep apnoea.

The coroner said: ‘He remained in hospital until May 3, at 10am, when he was found with his head trapped between the rails and mattress of his hospital bed.

‘He suffered a cardiac arrest – from which resuscitation was not attempted – and he died at 10.15am.’

He lamented how the NHS operates on the wrong body part once a week on average — a never-event called ‘wrong site surgery’ in official reports. 

And he claimed that trusts were under-recording the true scale of the problem.  

However, patient charities and experts say levels of never events are still too high.

In fact, wrong site surgery was recorded three times a week in the NHS on average in 2022/23, the latest year of complete data — triple the figure recorded when Mr Hunt first spoke out.

The Royal College of Surgeons said the level of never-events was ‘unacceptable’ and blamed NHS staffing levels for increasing the risk to patients. 

‘Surgeons will be working hard to do their best for patients, but they do so in difficult circumstances,’ a spokesperson said. 

‘The NHS is overstretched, with staff shortages, a workforce suffering from burn-out and pressure to get record waiting times down. 

‘This increases the risk of mistakes happening. 

‘While we now have a workforce plan for the long term, more needs to be done to fill vacancies and retain NHS staff right now.’

Patient safety charity Action against Medical Accidents said the data uncovered by this website suggested the NHS was failing to learn from never-events and that the problem could even get worse in the future. 

Paul Whiteing, its chief executive, added: ‘That we see similar numbers every year suggests that lessons are not being learned in the ways hoped.’

‘We are all becoming tired of hearing the phrase “lessons will be learned”. They are not being learned.

‘Investment and actionable change in the NHS is now long overdue.’

Rachel Power, chief executive of charity The Patients Association, added the human impact of never-events shouldn’t be underestimated, and that the NHS being busy should never be an excuse for such incidents occurring. 

‘Patients can experience serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS,’ she said.

‘Although the NHS is under significant pressure, these never events should not occur if the available preventative measures are implemented.’

The NHS’s latest complete year of data shows 384 never-events occurred in the NHS in England in 2022/23.

Private providers — who can carry out procedures on behalf of NHS services — are also included in the data. 

Such incidents include cases range from a surgeon operating on the wrong finger rather than the planned digit, to having an entire rib removed unnecessarily. 

In total, 1,806 such cases of wrong site surgery have been recorded across the NHS in England since 2013, the most of any type of never-events.

Barts Health NHS Trust in London has recorded 85 events since 2013, the most in the entire country. 

Rounding out the top three was London’s Guy’s and St Thomas’ (84) and University Hospitals Birmingham (83).

NHS trusts in East Suffolk, Essex, Manchester, Leeds and Liverpool also featured in the top 10.

Ramsay Health Care UK, a private provider with 37 facilities across country, was the only independent to make the list (58).

It is unknown if incidents recorded in the private sector are solely taxpayer-funded procedures being carried out there, however. 

An organisation recording a higher level never-events doesn’t necessarily mean it is more dangerous than its contemporaries.  

Larger NHS trusts carry out a higher volume of procedures per year, meaning they will inevitably have more never-events than smaller ones.

Some of the most common type of never-events in the NHS are surgeons performing an operation on the wrong part of the body and medics leaving objects behind in patient’s bodies after surgery. This graphic shows some of the most shocking examples. Source: NHS

Additionally, reporting never-events can signal a better safety culture because staff are more likely to admit such incidents rather than potentially sweeping them under the rug. 

But that doesn’t detract from some of the horrifying injuries some Brits have suffered as a result of these incidents.

In one case, recorded in 2015/16, an unnamed woman had one of her fallopian tubes removed instead of her appendix, which was meant to be extracted.

Notes describing the incident blamed the fact she was heavily pregnant at the time, and the ‘distortion’ of her anatomy, for the mistake.

Two men also suffered eye-watering injuries from medical mistakes to their reproductive organs. 

One man in 2019/20 was scheduled for a frenuloplasty, a specific procedure to cut away a tight fold of skin on the underside of the penis to increase its range of motion, when the mix-up occurred.

Gauze left behind after surgery contributed to man’s fatal cancer  

Frank Hibbard went under the knife in 2001 for an operation to remove his prostate cancer.

Then 56, Mr Hibbard was told the operation should rid him of the disease entirely as the cancer was entirely contained within the prostate gland.

The long-distance lorry driver had hoped this would give him many more years with his wife Christine and their three children.

But what he didn’t and couldn’t have known is that his surgery at the Luton & Dunstable University Hospital had left a ticking time bomb inside of him.  

Frank Hibbard went under the knife in 2001 for an operation to remove his prostate cancer but medics left something behind

Surgeons had accidentally left an 8cm-long piece of gauze inside his pelvis from the operation.

This tragically triggered the development of a soft-tissue cancer called angiosarcoma.

Compounding his suffering multiple chances to spot the cancer were missed leaving him to suffer from years of pain.

By the time medics did spot the cancer in March 2014 it was so advanced that nothing could be done to save Mr Hibbard’s life.

 He died that same year, aged 69.

A coroner’s report concluded the swab left inside his body had ‘materially contributed’ to the development of the cancer.

‘Several agents are known to predispose formation of angiosarcoma including a surgical sponge or gauze retained for a prolonged period in a body cavity,’ it read. 

Such cancers can develop from the tissue the body grows around the foreign object.  

His widow, Christine, a former legal secretary from Luton, said she was devastated when she learned what had caused her husband’s cancer.

‘Part of me died that day,’ she said. 

The year before, a man booked in for a cystoscopy, a procedure where a tiny flexible camera is inserted into the urethra to examine the interior of the bladder, instead awoke to find he had been circumcised instead. 

Dozens of other Brits have suffered similar harms, such as having ovaries removed during procedures without their consent or having the wrong testicle amputated.

Other bizarre surgical incidents saw patients get pacemakers they didn’t need, cranial plates installed that were custom designed for another patient’s skull and biopsies collected from their lungs instead of the planned bowel. 

Some patients even got contraceptive implants installed into their bodies they never requested.  

In a case recorded just this year (2023/24), a patient booked for a kidney transplant received an organ with the wrong blood type, meaning their body rejected it.

Kidney donations can give Brits stuck on dialysis a new lease on life. Most patients wait two years before a donor organ becomes available.

MailOnline’s audit also revealed 1,088 cases related specifically to objects being left inside patients.

Items found range from scalpels, needles, forceps, gloves to ‘part of a condom used during a surgical procedure’ back in 2020/21, at the height of the Covid pandemic. 

Vaginal swabs, medical tools designed to get samples of vaginal fluids for testing, were one of the most common items medics lost and/or forgot to remove each year, with over 300 such cases recorded since 2013.

Other never-events involve cases outside of direct surgical or medical procedures. 

Two patients ended up getting their neck or chest trapped between their hospital bedrail and the mattress, with at least one being fatal.

Max Dingle, an 83-year-old retired police officer, died 15 minutes after being found with his head stuck in such a situation.

He died on a ward at the Royal Shrewsbury Hospital on May 3, 2020.

Other non-surgical incidents included 14 cases where staff scalded patients with hot water during their care.

One of the rarest types of never-event recorded is prisoners escaping from custody during NHS care.

Only three such escape incidents have been recorded, two in 2014/15 and another the year before.

Previous estimates have put the annual bill of compensating patients and families for never-events at £800million.

With an average of 415 never-events per year, this equates to roughly £1.9m for each incident, though amounts will vary hugely depending on the case.

Linda Millband, a partner in the clinical negligence team at law firm Thompsons Solicitors, said: ‘Any evaluation of damages considers the extent of harm suffered, the impact on the patient’s quality of life, potential ongoing healthcare needs, and the psychological trauma involved.

‘Moreover, factors such as loss of earnings, the cost of care, and any necessary adjustments to living arrangements may also influence the final settlement figures.’ 

An NHS England spokesperson said staff work ‘exceptionally hard’ to keep patients safe but never-events, while rare, are fully investigated.

‘Thankfully, never events are extremely rare, however when they do occur NHS trusts are mandated to investigate what has happened and take effective steps to improve as part of our patient safety strategy,’ they said. 

About 415 never-events occur each year in England on average, figures for 2023/24 (the dotted line) are incomplete but already stand at 179

A Department for Health and Social Care spokesperson added: ‘The safety of all patients is of vital importance and these unfortunate events – although rare – can have a serious physical and psychological impact.

‘When never events do occur, we require trusts to investigate them and take effective actions to improve safety as part of the NHS Patient Safety Strategy.’

Medics leave tampon inside new mum, leaving her in agony

A 2019 report by the Health Services Safety Investigations Body (HSIB) detailed the case of women known only as Christine.

The new mum, aged 30 at the time, had a surgical tampon inserted after the birth of her first child.

Surgical tampons are much larger than normal versions used for periods and should be removed at the end of a surgical procedure.  

But staff left the object inside her for five days.

Surgical tampons are much larger than normal ones (pictured, bottom versus top) and are supposed to be removed when a procedure is finished. Leaving them in can have devastating consequences

Christine was left in agony but couldn’t understand why.

HSIB’s director of a maternity investigation programme Sandy Lewis said: ‘There are numerous physical effects; pain, bleeding and possible infection, but we can’t forget about the psychological impact as there was in Christine’s case.’

‘She had to seek private counselling and felt that what happened affected her ability to bond with her baby.

A spokesperson for Barts Health NHS Trust: ‘Keeping patients safe is our top priority and we take these incidents very seriously. 

‘While they should never happen, we encourage staff to report them when they do occur so we can learn from mistakes and reduce the risk of recurrence in future.’

A King’s College Hospital NHS Foundation Trust spokesperson said: ‘Patient safety is our number one priority, and we have a strong reporting culture at King’s. 

‘Although we safely treat high numbers of patients every year across our hospitals, if a never-event occurs, we ensure it is fully investigated, and that lessons are learned to improve the care we provide.’

A University Hospitals Birmingham NHS Foundation Trust spokesperson said patient safety was the Trust’s priority ‘above all else,’. 

‘Where we do get it wrong, a full investigation is conducted into all never-events by senior clinicians,’ they said. 

‘These investigations aim to establish the full range of learning available, involving patients and their families, to help us improve the quality and safety of clinical care and prevent reoccurrence.’

A spokesperson for Ramsay Health Care UK said the provider the reporting of ‘patient incidents’ seriously. 

‘All events are fully investigated, and any lessons are shared with our teams to ensure we have continuous improvement in the quality of care we provide,’ they said.

All named trusts were contacted for comment on their never-ever events data. 

The NHS, while having recorded never-events for over a decade, has changed how that data has been measured in that time.

For example, prior to 2014/15, they have only included incidents where a patient was directly harmed.

However, this was then expanded to also include incidents with the potential to harm a patient. 

This led to a sharp rise in the number of never-events recorded in subsequent years.

A more minor change was made in 2017/18 when the NHS shuffled the sub-categories it used to split never-events into different types of cases. 

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