NHS England has published the following framework and Never Events list:

NHS Never Events policy and framework

Latest NHS Never Events list (2018)

• Never Events are incidents that require full investigation under the Serious Incident framework.
• Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.
• Each Never Event type has the potential to cause serious patient harm or death.

As with other incidents that are classified as Serious Incidents, Never Events must be reported to both the strategic executive information system (StEIS) and the NRLS until the new patient safety incident management system is in place.

The Never Events reports for England can be found here. At the current time, only England publishes Never Event incidents, but the data may also be held with relevant authorities in Scotland, Wales and Northern Ireland.

Under the Wrong Site surgery category, incorrect skin lesion removals or biopsies are the third most common incident subtype, behind incorrect site blocks and teeth removals. The table below shows some recent statistics:

* Provisional data.

Common Problems

Through reviewing wrong site surgery reports both recent and historical, there are a number of commonalities between different Never Event incidents. Some of them are listed below:

• Failure to follow the WHO checklist correctly
• Failure to double check with the patient the site of surgery in situations where the use of mirrors would be beneficial.
• A fault in communications between doctors, nurses and other healthcare professionals. Junior members of staff need to be able to flag up issues and challenge senior clinicians (in particular, locums) about adherence to surgical procedures and risk to the patient.
• Misplacement or insufficient management of paperwork relating to the procedure.

All staff involved in surgical operations should be involved and/or represented in clinical governance meetings.

Responding to harm and duty of candour

• Inform patients promptly and openly of any significant harm that occurs during their care, whether or not the information has been requested and whether or not a complaint has been made.
• Act immediately when patients have suffered harm, promptly apologise and, where appropriate, offer reassurance that similar incidents will not reoccur.
• Report all incidents where significant harm has occurred through the relevant governance processes of your organisation.
• Reflect on any unanticipated events in a patient’s care that you have been directly involved in and present them for discussion at appraisal.
• Treat complaints from patients or their supporters with courtesy and respect, and recognise the value of complaints for monitoring and improving care quality. Respond to complaints promptly, openly and honestly and cooperate fully with local complaints procedures, acknowledging harm and offering redress where appropriate.
• If a consultant considers that a complaint is unjustified or vexatious, they should refer it to the medical director or an appointed arbitrator for independent review and early resolution.
• Participate fully, openly and promptly to any investigations relating to the occurrence of significant harm, following local guidelines. If you appear to the Coroner’s Court, you should provide prompt and complete evidence including comprehensive and truthful reports.

Serious Incidents Framework

Published in 2022, the Patient Safety Incident Response Framework (PSIRF) replaces the previous Serious Incidents Framework that was published by NHS England in 2015. The PSIRF is a departure from the Serious Incidents Framework which focussed on individual cases of patient harm and looks instead at the wider system of improvement for healthcare organisations. The PSIRF will come into force Autumn 2023 and is mandated by the NHS Standard Contract.

In the wider picture, national and local standards have been produced an implemented with the intention of providing a safety structure for the prevention of these serious incidents. The BAD has also produced a National Safety Standard for Invasive Dermatology Skin Procedures (NatSSIP) guidance for ensuring safety procedures in skin cancer. This coincides with the local guidance (LocSSIPs) produced by healthcare trusts to ensure standards of care. LocSSIPs must be used in conjunction with the WHO checklist.

On the 19^th of May 2021, the BAD held a multidisciplinary workshop on the recent rise in Never Events, with a view to producing a report on lessons learned and recommendations. The workshop was attended the Patient Safety Lead of the Never Events team of NHS England and Improvement, Fran Watts, who gave a presentation on the Never Events overview. This presentation can be viewed below.

Learning from 85 cases occurring in English hospitals between April 2018 and March 2022. This is a live report that will be updated annually as part of a continuing review into wrong site surgery Never Events in Dermatology.

The BAD provides surgical reviews to help Trusts experiencing serious incidents and Never Events. For more information, or to request a review, please contact us using the contact form below.