Doubling of NHS 'never events' never happened

11 September 2013

This article was updated at 6:15pm

Sometimes, and often with tragic consequences, NHS patient care goes badly wrong. These 'never events' are what the Department of Health (DH) terms "serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers."

According to at least four papers last week, 299 such incidents occurred in the 2012/13 financial year. This sparked a consistent array of headlines:

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Except this isn't the case. NHS 'never events' have not doubled. In fact, they've fallen. Full Fact got in touch with NHS England who, after some delay, clarified that the figures used by the papers were actually taking figures from two different - and non-comparable - datasets:

"The correct comparison is between data taken from the NHS serious incident management system (STEIS), which shows that the number of never events reported in the NHS was 326 in 2011/12 and around 299 in 2012/13 (note this latter figure is subject to alteration following further verification)."

So the available data (that isn't yet fully verified) actually suggests the number of never events is falling, not doubling.

What went wrong

It all comes down to measurement. The concept of a 'never event' has been around since 2009 but started out with just eight different 'categories'. Since 2012, the list has been expanded to cover 25 types of incident, everything from surgery in the wrong place and 'foreign objects' left in the body after an operation to badly scalding patients and allowing transferred prisoners to escape.

But, surprisingly, these aren't all recorded in one place. Formerly a never event was reported to a Strategic Health Authority (SHA) when these still existed, but some were also reported to a database called the National Reporting and Learning System (NRLS), which centrally collates patient safety incident reports. As the DH points out:

"This is a separate reporting system and the majority of these reports correspond to incidents also reported to the SHAs, so the totals cannot be added together."

In fact, the figures can differ a lot. Last year (in 2011/12) SHAs recorded 326 never events, but the NRLS only recorded 163. That 163 figure was used in the comparison with this year's 299 figure - hence the claims that incidents have 'doubled'.

Now that NHS England has confirmed the 299 figure is from the 2012/13 SHAs data, it's the 326 figure we should be using in comparison with this year.

This is all still very confusing of course. The good news is that the NHS itself is aware of this, and is developing a single system of incident reporting. From next month, NHS England will be publishing records of never events on a quarterly basis. 

Waiting on corrections

While it might not be the press' fault that the earlier numbers were confused, the record still needs to be corrected. NHS England confirmed that a letter of clarification has been sent to the papers involved. We'll be keeping watch to make sure the matter is set straight.

This article was updated after NHS England provided a clarification

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