List Proves No Room For ‘Never Events’ In NHS

Lawyers Welcome Steps To Secure Patient Safety

18.03.2011

Patients’ rights experts representing victims of medical errors including a North East man with a needle inside his arm for two years have today called for a recently-published ‘never event’ list to become key literature for all medical staff across the country.

The call comes from law firm Irwin Mitchell following the release of the extended list published by the Department of Health, which highlights 25 serious, preventable patient safety incidents that should never occur whilst in the care of the NHS.

Stephen Winn, from the firm, also welcomed a new incentive to secure patient safety as a top priority, with hospitals facing financial penalties if such errors occur but voiced concerns that some injuries, such as bedsores and those caused by administering substances to patients with known allergies were not included.

The new list adds tragedies such as maladministration of insulin, falling from unrestricted windows and severe scalding to those already identified on the original list of eight published in April 2009, including medical instruments and swabs being left inside patients bodies, and operations being carried out on the wrong body part.

Mr Winn is representing a South Shields man, Stephen Oliver, 41, who endured excruciating pain for two years after a broken hypodermic needle was left in his arm following a series of steroidal injections to treat his tennis elbow.

The legal claim is still being investigated against the two treatment centres that administered Mr Oliver with the injections, from November 2007 until September 2009 – a GP surgery in Shields, and the Musculoskeletal Unit of South Tyneside PCT. Both are currently denying the claim.

Despite Mr Oliver’s ongoing complaints of pain in his arm, the needle was not detected until he was referred to the Queen Elizabeth Hospital in November 2009 – he was x-rayed immediately there and the needle was surgically removed, leaving him with a six-inch scar on his arm. He still suffers from pain in his arm.

Now Irwin Mitchell is urging medical professionals to take the time to consider the incidents highlighted on the official list to ensure that every step is taken to prevent further such horror stories emerging.

Mr Winn, from Irwin Mitchell, said: “Whilst we welcome these new steps to make patient safety a priority the fact remains that such a list has existed since 2009, and we are still being contacted time and time again by the victims of wholly avoidable errors which often have catastrophic consequences.

“Never events should be just that, events which never occur, and it is imperative that Trusts across the country invest time and resources to ensure every step is taken to protect the safety of patients and prevent injury where at all possible.

“If withholding payment to a Trust for providing care which breaches these standards improves quality of care overall, that is surely something that must be welcomed.”

Mr Winn goes onto urge the DoH to keep the list under constant review in an effort to highlight even more avoidable errors as never events. He said: “If the wider NHS is to truly learn from patient safety incidents it is important that this list remains a work in progress, that healthcare professionals continue to identify new ‘Never Events’, and new ways to ensure that they do not occur.”

Mr Oliver described the pain that the ordeal has left him in: “The injury happened when I was rowing on holiday in 2007 – my elbow became swollen and very painful and my GP diagnosed it as tennis elbow.

“My first injection was incredibly, intensely painful and I suffered from swelling in my arm for two weeks. I was convinced something was wrong but was told the injection must have hit a nerve – I was denied any further inspection of the arm, despite repeated requests for an x-ray or scan of the area and I was assured that the symptoms I was experiencing were typical of tennis elbow.

“I attended another five or six appointments and no x-ray was ever carried out – the treatment was becoming less and less effective. I was struggling with my studies as I found it hard to use a computer keyboard, and I needed orthotics to help me drive.

“I was absolutely staggered when I was eventually x-rayed and the needle was found in my arm. To this day I still suffer with pain and stiffness in my arm and it continues to swell.”